Besting human nature

A KP innovation in how medications are dispensed to hospital patients is greatly reducing the possibility of dangerous errors

July 24, 2008

Interrupting a nurse can be hazardous to a patient's health—and yet it happens all the time.

Nationwide, one medication error occurs for every day a patient is in a hospital, according to a 2006 Institute of Medicine study. Some 7,000 patients die each year as the result of medication errors, the study showed, and $3.5 billion is spent each year treating medication injuries.

But at Kaiser Permanente, a new protocol is directly addressing the leading causes of such errors: Interruptions to nurses and the lack of a standardized process.

"Nobody ever thinks that medication administration is so important that you can't be disturbed," said Melody Navarro RN, labor co-lead of West LA's med-surg targeted unit-based team (T-UBT). "A transporter could say, 'I'm taking this patient,' and you're holding the medication. Or, 'oh someone's on the phone,' or, 'the doctor wants to talk to you.' Your concentration is broken."

The protocol, dubbed MedRite, was born at the Sidney Garfield Innovation Center, developed in collaboration with frontline workers at three facilities—West Los Angeles, Hayward and South San Francisco—and launched recently in inpatient settings throughout Northern California and the Northwest.

Interruptions drop by half

MedRite achieved overwhelmingly positive results in the departments in which it was tested and developed. Over a two-month period, the West LA T-UBT and departments in Hayward and South San Francisco experienced an overall 50 percent reduction in the number of staff interruptions, a dramatic drop in medication errors and a reduction in the average time it took for nurses to complete those medication passes.

"It's not that we don't know what to do," said VP of Patient Safety Management Doug Bonacum. "It's that we (didn't) know how to execute it reliably."

Eventually, MedRite will be used in all KP inpatient settings—and it's already being looked at by hospitals elsewhere.

It's estimated there are more than 20,000 prescription drugs out there. KP issues roughly 1,000 medications in inpatient settings. With the number of new and potent medications increasing, it becomes even more crucial for nurses—who typically bear the responsibility of administering drugs at the bedside—to focus solely on the task at hand.

"When a nurse goes to school, they're taught the five rights of medication administration," West LA medical-surgical department administrator Michelle Cotton said. "But after that, they're left on their own."

MedRite, which was conceived at a two-day brainstorming session in spring 2007 at the Garfield Center in Oakland, changes that. The nurses and other frontline workers involved quickly targeted one of the biggest hurdles nurses encounter while administering medications—frequent interruptions.

They decided they needed the equivalent of a "do not disturb" sign—and came up with the idea of "non-interruption wear."

After several incarnations, an inch-wide reflective sash emerged as the preferred design. The team in South San Francisco, which was working independently and then joined forces with the MedRite group, came up with the idea of a light jogger's vest.

MedRite Successes

How it works

Sash or vest, the approach is the same: Before a nurse goes in to retrieve drugs from the medication room, she dons the gear, and then keeps it on through the entire process of dispensing medications. The reflective gear signals to doctors and other hospital workers that the nurse is to be left alone, barring an emergency, until the gear comes off after the last patient has been attended to.

Another innovation was the creation of a "safe zone" around the PYXIS® machine, a computerized medication management system. There's also a checklist of basic steps, reminding nurses to wear the sash or vest, turn down the TV or radio in a patient's room, verify a patient's identity, and immediately record the medication in the patient's electronic health record.

By standardizing the process, MedRite goes beyond "right patient; right medication; right dose; right time; right route," making the task safer and faster.

"I think my staff felt empowered to say, 'No, don't talk to me right now. I'm in the middle of passing meds,' " Cotton said. "They're feeling more like they have more control."

Partnership and collaboration

At the West LA facility, members of the oncology med-surg T-UBT, which launched the pilot, say partnership was invaluable for getting the program off the ground.

"Sometimes you have a lot of ideas as a unit, but without support from other nurses for that, it doesn't come to fruition," said labor co-lead Navarro of UNAC.

Similarly, collaboration was a key element in developing MedRite in Northern California.

"For once, we were driving the project," said Mary Lou Ramirez RN, who is co-chair of South San Francisco's Quality Committee and a member of California Nurses Association."Management allowed staff RNs to work on the project to make a difference in delivery of care."

South San Francisco had begun developing its own program at the same time MedRitewas being piloted in West LA and Hayward. Clinical administrator Becky Richards said she and others wanted to take extra steps to ensure that no employee at the facility ever would have to endure the consequences of a serious error.

"Can you imagine? Nurses come to work to help patients and their suffering," Richards said.

Among other steps, Richards volunteered her staff for the California Nursing Outcomes Coalition, which tracks medication incidents not usually recorded as "medical errors." Employees came up with the idea of having nurses wear reflective vests while passing out meds, and rolled it out in April 2007. When MedRite folks got wind of their work, the teams started working together.

Using the nursing coalition standards, the medical center saw a 20 percent reduction in medication errors across all departments in the first month except for the one unit, Central East, which had declined to take part because it had always maintained the lowest med errors in the center.

What about multitasking?

"We thought it would hamper our multitasking," said Lani Guiao RN. Taking the vests on and off would be a hassle, they thought, not to mention looking unprofessional. "We thought it was going to slow us down."

As other departments conducted initial tests of the procedures, however, Central East not only failed to record a reduction in med errors—they saw an increase.

The data from other departments convinced the unit to join in, but, Guiao said, she became a true believer when she experienced its benefits for herself.

"It really did not alter my routine," Guiao said. "And it helped us teach patients that medication administration is a serious task."

Doctors and ancillary staff members had other concerns that had to be assuaged.

"The only issues that have come up were when we're looking for a nurse in a semi-urgent situation," explained Jason Anderson MD, chief of hospital-based specialists at South San Francisco.

Once the question of nursing coverage was resolved—and after seeing the statistics on the steady drop in medication errors—doctors have embraced the program

In Hayward, Xavier Yabut RN also resisted the gear initially. His turnaround came when patients who had become accustomed to the routine with other nurses asked him why he wasn't wearing the sash.