People, Process, and Technology Combined to Assure Save Medication Practices

Purpose:
Computerized medication systems have solved problems and created unintended consequences with this complex, interdisciplinary process. Failures cause care delays, work-arounds, diminished trust, and divisive behaviors. The purpose of our innovative effort is safe-guarding medication practices.

Significance:
Medication errors occur with unacceptable frequency in hospitals - sometimes with devastating consequences. In preparation for bar-code medication administration (BCMA), safe guarding the medication process prior to the addition of more technology, is essential for success.

Strategy and Implementation:
Our objective was to create safe medication practices by carefully integrating people, work process, and technology; using data from our electronic systems to provide information about processes; and building the infra-structure required to continuously improve. Improvement was necessary in a number of areas: the reliability of hardware and software, eMAR information, and medication delivery; the meaningfulness of medication-related alerts; and compliance with medication reconciliation. We created structures and processes for continuous improvement in our systems for medication ordering, preparation, delivery, and administration. A variety of innovative process improvement strategies were employed to engage team members. Included were unit-based surveys - simple enough to answer on the fly; Six Sigma approaches to simplifying the environment, our electronic tools, and our processes; and data utilization at the unit level to drive continuous improvement.

Evaluation:
Success was measured by: Decreased incidence of 'missing' medications Decreased pharmacy turn-around-time Improved on-time medication administration Reduced automated medication alerts Decreased voluntarily reported medication events Increased compliance with medication reconciliation

Implications for Practice:
Each member of the inter-disciplinary team is accountable for safe medication practices. Strengthening team members' effectiveness improves reliability of medication processes. Enhanced collaboration and reliable information provide the infrastructure and resources needed to continuously improve.