“We had some great results, some important safety improvements. But … we need to take the next big step, and I am hoping someone out there has cracked the code.”
- Joanie Ching, RN
Every morning around 8 to 9 a.m., the vast majority of the more than 5,000 hospitals in the United States experience the same routine: Nurses administer medications to patients. Virginia Mason’s Joanie Ching, RN, MN, administrative director, Quality and Safety, says this phenomenon seems to have been cemented into the medical culture for several decades. Joanie worries because she doesn’t think it is the safest way to protect patients from medication errors.
Joanie’s expertise on medication safety is well established. She is the lead author of an article in The Joint Commission Journal on Quality and Patient Safety entitled, “Using Lean to Improve Medication Administration Safety: In Search of the ‘Perfect Dose’” (May 2013). She and her co-authors (see below) are currently working on a follow-up to the article.
The problem with this longstanding approach to the distribution of medications to patients, says Joanie, is that it happens in batch production, which is inherently inefficient and wasteful. Uneven flow stresses the system, and when the system is stressed, people rush. That results in defects, including medication mistakes.
“Continuous flow is an essential hallmark of the Virginia Mason Production System because we know how much better any process works when it is in flow,” says Joanie. “When we studied the medication administration process in our hospital, it was clear that under the traditional approach, nurses cannot achieve continuous flow. During that morning peak period of medication distribution, nurses are unavailable to other patients and team members. So they may not respond to an opportunity to add value in the patient’s experience — patient education or emotional support, for example.”
Why is the absence of smooth flow not in patient’s best interests?
“Think about it this way,” says Joanie. “Every morning nurses line up at the medication dispensing station where all of the process is computerized for efficiency and safety. And that’s great. But there is a line of nurses waiting to get meds for their patients, and nurses hate to wait. So what do they do? They say, ‘OK, I know the rule is that I should only take one patient’s medication at a time, but because I’m pressed for time, I’ll take two or three patients’ medications and separate them as best I can — one patient meds in my right pocket and another in my left pocket.’”
Nurses do this not because they want to care for patients in an unsafe manner, but because they are trying to get the patients’ medications to them “on time.”
“The irony is that nurses find a way around the process because they’re trying to do a great job!” says Joanie. “They don’t know any differently but they see it as a barrier between themselves and their patients. Still, the fact is that a majority of meds are being given in the morning and not in afternoon when it is perfectly fine to give meds.”
When Joanie studied the medication administration process at Virginia Mason, she found too many errors and realized many, if not most, resulted from distraction — nurses getting interrupted during the medication distribution process.
After a significant amount of study strengthened by several Plan-Do-Study-Act (PDSA) initiatives, a new process was implemented that placed a visual boundary on the floor at the medication station. The new rule was that when a nurse was in that area getting medication, no one would talk with the nurse or interrupt them in any way except in an emergency. The clinical teams also agreed that anyone waiting to use the dispensing station would wait outside the medication room, rather than inside where conversation with others may distract the person preparing medication.
This new approach resulted in significant improvements. As Joanie and her coauthors noted in the Joint Commission article, “Overall ‘perfect dose’ delivery increased from 37% to 68%, and medication administration errors decreased from 10.3 to 2.8 errors/100 doses.”
“We had some great results, some important safety improvements,” says Joanie. “But — and there is an important but — we need to take the next big step, and for all of our work and analysis, we are having trouble getting there. So I am hoping someone out there has cracked the code.”
What does get there mean in practice? It means Joanie and her team would like to distribute medications in a smooth and continuous flow. This would include administering medications that must be given on a specific schedule — at mealtime for certain medications, for example, or every six hours for antibiotics. Still, other meds are delivered on a patient-preferred schedule.
“We honor all of that absolutely,” says Joanie, “But we found through a PDSA two years ago that these categories account for no more than about one-third of all medications — meaning if we could figure out a way to distribute the remaining meds scattered evenly throughout the patient’s waking hours, it would be much safer and reduce the burden of work on nurses, freeing them to do their jobs more effectively.”
We want to smooth flow, because by doing so, we reduce the likelihood of making errors,” she says. “The goal is more even distribution of the other meds not tied to a specific schedule or time of day — throughout the whole day — optimizing medication flow throughout the 18 hour waking day.”
Accomplishing this, says Joanie, would “create smooth, continuous flow with nurses getting meds to patients in more level manner throughout the day with less stress on the system. This would free nurses to be part of multidisciplinary rounds in the morning and it might make patients more satisfied.”
The question for Joanie and her team is how to optimize the med administration schedule so there is less batching in the morning, and then continuous smooth flow throughout the remainder of the day. This means abandoning the old model, while at the same time honoring patient preferences and respecting staff members.
Having spoken with a variety of people at universities, the Institute for Healthcare Improvement, the Joint Commission and Cerner, Virginia Mason’s electronic health record vendor, Joanie believes the answer must be out there but she has not found it. And she is looking for help.
“There is huge opportunity for level loading,” she says. “And I am hoping to find someone who has solved this so we can do the same thing.”
Can you help Joanie? What have you done at your organization to improve the safe administration of medication to patients?