EP03.01 - Medication Error Reduction with Closed Loop Medication Administration
e-Health ePoster Library. Ayres S. Jun 7, 2016; 131562; EP03.01
Stephanie Ayres
Stephanie Ayres
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Abstract
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Purpose/Objectives: Use of barcode identification during medication administration for positive patient identification and medication order (no baseline data as did not use barcode prior to project implementation) led to a reduction of medication error (classified as 'wrong drug/wrong patient') from 8/quarter to 3/quarter. Methodology/Approach: St. Joseph's Health Care London (St. Joseph's) (May 2014), along with nine regional organizations implemented Computerized Provider Order Entry (CPOE) as part of a larger project called HUGO - Healthcare Undergoing Optimization, to transform healthcare while improving quality of care and patient safety throughout the region. The three other components included within HUGO are: Closed Loop Medication Administration (barcode CLMA), electronic Medication Administration Records (eMAR), and electronic Medication Reconciliation (Med Rec). Specific activities/changes to the medication system that were implemented to ensure that medication errors can be reduced under HUGO included, but not limited to: each drug/dose is individually packaged and uniquely identified (barcode at the dose level); 'single tab per packet ' means converted from 'multidose' strip packaging; unit dose conversion for those sites not on unit dose; oral solid narcotics single tab packaged; new WOWs determined the 'cart'/'bin' refill/exchange system (increased exchanges at Parkwood Institute Main); GS1 standard barcodes are baseline for drugs and cross-referenced to the Pharmnet system for barcodes at the bedside; Barcoding system and processes for all unit dose and some bulk doses; 24/7 medication order verification by a pharmacist; evidence based and standardized medication prescribing (through approved order sets, which is a multi-disciplinary clinical process and involved the P&T Committees) barcode closed loop medication administration with direct link to medication order (CPOE) and eMAR e-medication administration record replaced computerized MAR (cMAR) barcode patient identification (eg. wristbands) for all patients and all sites - new wristband printers and labels The premise is that with positive identification of the patient, the medication and staff member, with active 'alert' firing in the system, there will be a reduction of medication errors that are 'wrong patient/wrong drug'. Direct linking to the eMAR from the prescriber's order (in CPOE) also ensures that the medication is for the right patient. Finding/Results: The implementation of HUGO streamlined the medication system and process and reduced multiple steps creating an efficient process; With (barcode) Closed Loop Medication Administration (barcode medication/dose, barcode patient identification, prescriber's medication order in CPOE, and direct linking to eMAR), the medication errors (wrong drug/wrong patient) have reduced from 12 per quarter (Q1 Fy 2014/15) to 2 per quarter (Q2 FY 2015/16). Conclusion/Implications/Recommendations: The initiatives under HUGO represented one of the largest cultural and operational changes that St. Joseph's has undertaken. All components of the HUGO project directly impact the medication system and have the potential to elevate our practice by providing a safer medication system for our patients (keep our patients safe. The premise is that with positive identification of the patient, the medication and staff member (closed loop medication administration), with active 'alert' firing in the system, there was a reduction of medication errors that are 'wrong patient/wrong drug'. Additionally, directly linking to the eMAR from the prescriber's order (in CPOE) also ensures that the medication is for the right patient. 140 Character Summary: Closed Loop Medication Administration reduced medication errors (wrong drug/wrong patient) from 12 per quarter (Q1 Fy 2014/15) to 2 per quarter (Q2 FY 2015/16).
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