Transcript Improving the Accuracy of Medication Profiling

Innovation Poster Session
HRT1215 – Innovation Awards
Sydney
11th and 12th Oct 2012
Improving the Accuracy of
Medication Profiling Process
Presenter: Prathna Singh, Prem Kumar
Hospital Code Name: Counties Manukau District Health Board
4-4d_HRT1215-Session_SINGH_CMDHB_NZ
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KEY PROBLEM
Background
 Availability of the right medication at the right time is vital for
patient care; any error can lead to a serious outcome. With
the introduction of the Pyxis system, an automated
dispensing machine, drugs can be accessed from machines on
the wards using patient medication profiles that Pharmacy
staff compile electronically using the patients medication
chart.
Problem
 The medication charts received by pharmacy are not always
accurately profiled with what is prescribed. This can lead to a
Nurse accessing and then administering the incorrect
medication it to a patient.
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AIM OF THIS INNOVATION

The aim of this improvement was to
reduce the number of near misses in the
profiling process, therefore increasing the
accuracy of the patient profile of
medications available to nurses on the
ward.
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BASELINE DATA

An audit of 100 charts over one month found that 10 patient
profiles that appeared on the Pyxis machine did not match
what was charted for the patient on their medication chart.
Collecting this data was time consuming and required a lot of
staff resource, hence the team devised the idea of collecting
the “number of near misses” in Pharmacy as a proxy
measure.

These errors in the first step of the profiling process
increased the possibility of errors getting past the final check
and therefore the possibility of nurses accessing and
administering incorrect drugs to a patient.
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KEY CHANGES IMPLEMENTED



Interruptions
 Telephone - PABX system was introduced and phone placed in relevant
areas to reduce the telephone interruptions while profiling
 Sitting Layout- New sitting arrangement identified to accommodate the
process flow and reduce interruption from other processors.
Standardised process for profiling
 Annotation - Variation in the way each person profiled a medication
chart was reduced by standardising the annotations used on medication
charts.
 Process steps - Checklist created for the process.
Knowledge management
 Standardised Training
 Staff Credentialing
 Dashboard created to initiate improvement discussions
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OUTCOMES SO FAR
Monthly Near Miss in Pharmacy
120
Improvements
identified and trialled
Count of Near Miss
100
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LESSONS LEARNT


Improvements that come from the team to make changes
more sustainable.
Proxy measures can be used to measure the improvements
instead of relying on time consuming one off audits.
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