Medication Scanning

Medication
Scanning
Compliance
McKesson Quality Achievement Award
Finalist Presentation
February 8, 2012
Not-For-Profit
Community Hospital
Regional Referral Center
222 Beds
13,000 Admissions
53,000 ED visits
1,200 Deliveries
8,000 Surgeries
2,000 Employees
250 Physicians
Net Operating Revenues of
$200,000,000
Who We Are
Appalachia
Relationships
Six Sigma
McKesson
Where We Are
The Error
The Impact
The Mistake
Root Cause
Analysis
Opportunity
The Follow-Up
Workflow
Process
Accountability
Dangerous
The Debrief
Staff
Nursing
Leaders
IT
L&D
Patient
Resp
Inter-Disciplinary
GB Members
Therapy
Pharmacy
Six
Sigma
The Team
Scanning Compliance: April 2009
51% Defects
The Baseline Data
OMG !
This is Scary
Where Else?
The Gut Reaction
Admin Rx
Scan
Patient
Check ID
Check
Orders
Start
Scheduled
Meds
Obtain
Meds
Care Organizer
Scan
Patient
Check ID
Scan Med
Scan Pt
Give
Drugs
Give
Drugs
Scan Self
System?
- Problem Prone
The Process
No Standard Process
Monitoring
Reports
Staff Naiveté
Staff Accountability
Discipline
The Vital Xs
New Approach
Old Approach
Structured
Screen Shot
Learn
Demonstrate
The Approach
Interventions
Scanning Process
Staff Training
Policies/Procedures
Reports and Monitors
The Interventions
Start
Care Organizer
Scheduled
Meds
Scan
Patient
Obtain
Meds
Admin Rx
Verify Pt
Name/DOB
Scan Med
Validate
Order
Scan Pt
Give Med
Save
Scan Self
New Scanning Process
Mandatory Education
Online Modules (with Testing)
Order Verification & Error Reporting
Medication Administration
24-Hr Chart Check
Peer Review Observations
Validator Training
Staff Education
Skills Validation
Checklist Developed
Validators Trained
Different Units
Accountability
Skills Validation
New SOPs
AdminRx Med Administration
24-Hour Chart Check
Confirming Meds in Care Organizer
Accountability
Policies & Procedures
Reports
Monthly Unit Reports
Monthly Staff Reports
Compliance Graphics
Reports & Monitors
Scanning Compliance
65%
Reduction
P=0.000
The Results
Medication Events
65%
Reduction
P=0.000
The Results
Serious Medication Errors
P=0.062
67%
Reduction
The Results
Scanning Compliance > 99% in All Units
The Control Phase
Sustained Unit
Compliance
99.5%
Decreased Variation
by 89%
Sustain
Tempo Master
Opiate Training
Change in Performance
Standard Work
The Extended Gains
Final Results
65% Reduction – Scanning Defects
67% Reduction – Medication Events
67% Reduction – Serious Med Errors
99.5% Unit Scanning Compliance
89% Reduction – Scanning Variation
New Education Model
Changing Performance Culture
SAFER PATIENTS!
The Summary
Questions?