2. A Lean Approach for Improvements
in the Medication Order &
Dispensing Process –Inpatient
Pharmacy
Presented by:
Lynda Mikalauskas BScN, MBA, CPHQ
Silvia Calzada ASQ-CSSBB, ASQ-CSSGB, PMP, PMI-RPM
November 4th, 2015
3. Patient Safety
• The organization comprises Hospitals , Clinics, Medical
Centers and Pharmacies in four Emirates and two
countries.
• In line with our regulatory bodies such as HAAD, the
Dubai Health Authority, the Ministry Of Health and
accrediting body, Joint Commission International, we
seek to reduce the risk of patient harm.
• Risk of harm, linked to the medication ordering process
was identified in two of our hospitals.
• The risk involves the potential for wrong patient
identification.
4. To Err is Human Report: Building a
Safer Health System
• Published in November 1999
• By the U.S. Institute of Medicine
• 44,000 to 98,000 people die each year as a result of
preventable medical errors.
• Cost: between $17 billion and $29 billion per year
• In 2001, IOM published “Crossing the Quality of
Chasm” presented a comprehensive review of the
overall quality of the healthcare system in USA.
5. • Institute for Health
Improvement defines
medical harm as: Unintended
physical injury resulting from or
contributed by medical care
(including the absence of
indicated medical treatment),
that requires additional
monitoring, treatment, or
hospitalization, or that results
in death.
And Now after 16 Years
6. • In September 2013, the article “A
New, Evidence-based Estimate of
Patient Harms Associated with
Hospital Care” was presented in the
Journal of Patient Safety.
• Author: Dr. John T. James –
Retired Chief Scientist of Space
Toxicology at Johnson Space
Center, NASA, in Houston, Texas.
• The estimate is as follows: the
number of lethal, preventable
adverse events (medical errors) was
estimated to be more than 400,000
per year as a result of care in U.S
hospitals.
And Now after 16 Years
• Errors of commission, omission,
diagnosis, and communication and
infections were considered.
• Death was a result of a
combination of a serious
medical condition with
medical error.
7. • In 2008, researchers
estimated that
medication errors kill
7,000 Americans
annually.
• Medication errors that
result in harm are the
number-one cause of
inpatient fatalities.
Some Medication Error Statistics in USA
8. Medication Order and Dispensing Process
At Inpatient Pharmacy
• Our focus for this project: Improve the medication order
and dispending process to reduce the risk for medication
errors.
• Our current situation:
– The medication order process to prescribe medication for
inpatients is electronic for the order and a hardcopy for
documentation of the medication administration:
• Medication Order Label: Documentation of medication that
has been prescribed by the doctor,
• Medication Administration Record (MAR), is the
documentation of the medications to be given by nurse,
9. • Incident reports (OVRs) during April-May 2015.
• Incident reports identified:
– Adhering patient identification labels in wrong medication
administration report (MAR) or Inpatient .
– Physicians at one facility wanted to create medication orders
remotely and print the medication order labels.
– Serious risks of medication errors related to patient
identification
• It was decided that a task force be formed to address
evaluation, solution design, and implementation.
• A kick off meeting involving relevant departments and
stakeholders of both hospitals, leadership and staff
(Quality, Nursing, Pharmacy, Medical Staff) that would be
involved in the project was held.
Project Trigger
10. • Detect gaps in the medication ordering and dispensing
processes that were impacting patient safety
• Reduce the likelihood of these incidents
• Identify “easy to implement” solutions based on lean
tools. (Development in progress)
• Ultimate objective: reduce the number of medication
errors associated within the ordering and dispensing
processes.
Project Objectives
11. Summary of the Medication Order and
Dispensing Process
• The process starts in the inpatient units (e.g.
Surgical, ICU) and ends at Inpatient Pharmacy.
• Medication order is done by physician in inpatient
setting in an electronic environment (HIS).
• The medication order is a complete/written
prescription with the following information:
Medication name, route, frequency.
• Once the physician completes the medication
order, a label is printed.
12. Summary of the Medication Order and
Dispensing Process (cont’d)
• The physician places the label in the MAR/IDP.
• Nurse takes the MAR/IDP to Inpatient
pharmacy.
• MAR/IDP is used by the pharmacist to
dispense the medication. Pharmacist register
medication order in the PBM.
• MAR/IDP is used by the nurse to administer
the medication to the patient in inpatient
setting.
17. With a Lean Mindset, We Started the
Evaluation of the Process
– Lean is a systematic approach
to identifying and eliminating
waste through continuous
improvement.
18. • Process Map
• Gap Analysis
• Root Cause Analysis
Selection of Lean tools that were
applied in this project
19. Process Map Definition
• Also called process flowchart and process flow
diagram.
• Graphical description of the separate steps of a
process in sequential order.
• Elements that may be included are:
– Sequence of actions,
– Systems involved in the process,
– Decisions that must be made,
– People who become involved.
• The objectives of doing a process map:
– To develop understanding of how a process is done.
– To document a process.
– When better communication is needed between people
involved with the same process.
20. The 5W-1H of Kaizen Model to Build the
Process Map
21. Medication Order and Dispensing Process
Map
• The following information have been
identified:
• 23 steps
• 48 gaps
• 2 concerns
• The process was almost identical for:
• Medication order for inpatient (MAR) or,
• For medication order for patient being
discharge (IDP)
22. Observations/Challenges in Mapping
the Process
• The description of the process changed depending on which staff we were
interviewing.
• It is also complicated by the fact that there are two hospitals involved.
• The multi-disciplinary team needed to simulate the process up to 3 times
to get accurate /consistent information from the different sources.
• Attention to detail was required to map every step.
• IT systems in place are 15 years old.
• To make amendments in the Health Information System was very challenging
task.
• First the amendments would need to be collected and evaluated by a
multidisciplinary team. The changes would need to be doable in a short
period of time to benefit of those.
• Our organization is evaluating at the moment a new Electronic Medical
Records system which include complete medication system process
(order, dispense, administer).
23. Gap Analysis
• Gap Analysis -
– A tool used to identify a performance difference
between a current state and a desired state.
• Gaps analysis was performed in parallel of the
process map exercise.
• Main Findings of the Gap Analysis:
– Non compliance with existing policies
– Inconsistent use of counterchecking of medication
orders labels and patient identification labels on the
MAR
– Unsuitable staff being asked to perform key steps of
the process (non compliance with the policy)
24. Root Cause Analysis
• A root cause is a factor that caused nonconformance
and should be permanently eliminated through
process improvement.
• Root cause analysis uncovers causes of
nonconformance.
• Root cause analysis is a tool to help identify what,
how and why a nonconformance has occurred.
• Ultimately, action plan is putting on place to prevent
future nonconformance.
25. Results of Root Cause Analysis
• Numerous human errors (not 100% preventable)
• Technical factors (malfunction of printers,
computers)
• Lack of training
• Non compliance with the existing policies
• Lack of systematic approach and lack of counter
checking information in the MAR/IDP medication
order label
26. • Compliance with patient identification policy.
• Education + reinforcement of medication ordering and dispensing
policies.
• Ensuring verification on patient identification fields in medication
administration record and in-patient discharge prescription
documents:
– Patient name complete (first name, surname).
– Patient file number.
• Absolute restriction to print patient identification labels in non-
designated printers.
• Reduce the number of computers and printers in the units, in
which medication order labels are being printed. Locate the
computers and printers next to MARs files.
Action Plan
27. Selected Potential Solution: New medication
order and dispensing process
• Medication order is performed by physician and gets
registered in the HIS.
• Pharmacist gets HIS alert about the new medication
order. He follows policy to handle medication order:
– Patient identification counter check,
– Review of MAR ( medication history, allergies,
prescription type),
– Medication reconciliation,
• Pharmacist prints the label and adheres it to the
MAR.
28. Conclusions, recommendations and the next
steps
• Ensuring compliance of policies already in place through educational
program to reinforce behaviors that brings positive patient safety
outcomes.
• Update the Health Information System with specific features to
enhance the inpatient medication order process. (In-house or with a
new EMR).
• Proposal to modify behavior 1: For physicians, only print one label at a
time for only one patient (1-1). And stick immediately. All the rest of
the stickers found in the patient file, to be shredded for patient safety
purposes.
• Proposal to modify behavior 2: For nurses, never keep patient
identification labels inside the MAR. Always counter-check:
– Right patient, Right medication order, Right MAR (RRR)
• When modifying the medication order process, perform FMEA to
evaluate changes in the process
29. Significant Aspect of
Diminishing Risk
The creation and support of a “Just
culture” by leadership for patient and
organizational safety.
30. References
• www.Asq.org website of the American Society for Quality
• http://www.isixsigma.com/industries/healthcare/
• The Certified Six Sigma Black Belt Handbook, Second Edition.
• Lean, Six Sigma, and the Systems Approach: Management Initiatives for
Process Improvement. Robert B. Pojasek
• Sobering statistics – Article: Medication errors: Pamela Anderson, MS,
RN, APN-BC, CCRN, and Terri Townsend, MA, RN, CCRN, BC, CVN-II -
http://www.americannursetoday.com/
31. Acronyms
• Documents:
– MAR -Medication Administration Order
– IDP – Inpatient Discharge Prescription
• Prescription type:
– REG for regular,
– PRN – Pro Re Nata or “as needed”,
– STAT – STATUM or urgent, Single Dose
• Software:
– PBM Pharmacy Benefits Management Software
– HIS Health Information System
