Patient Safety. It’s one of the highest pri-orities in healthcare today. The Instituteof Medicine reported in 1999 thatapproximately 1 in 10 patients in theUnited States is injured and nearly100,000 die every year from preventablemedical errors. While most of the newsseems discouraging, many hospitals aremaking progress in bringing aboutimprovements in their patient safetypractices. To help recognize these health-care organizations, Precision DynamicsCorporation (PDC) and Patient Safety& Quality Healthcare (PSQH) cospon-sored a nationwide Partner in PatientSafety Success Story contest.

The contest was launched in March2008, during National Patient SafetyWeek. Hospitals were encouraged tosubmit patient safety “success stories”that demonstrated how clinicians useinnovative solutions and effective pro-cesses to help prevent medical errors andimprove patient safety. Essay criteriaincluded key areas of successful patientsafety practices, use of innovation andtechnology, effective implementation,measurement of results, and strategiesfor sustaining the improvements. Thewinning stories are available atwww.pdcorp.com/healthcare and serveto educate other facilities to maximizesafety and improve patient outcomes.The grand prize is PDC’s donation of$10,000 to the winner’s hospital founda-tion.Additionally, three runner-up hon-orees each receive $1,000 of PDChealthcare products.

“We were very impressed with thequality of entries received, as it was

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P A R T N E R I N P A T I E N T S A F E T Y

Success Story Contest Rewards Efforts to Improve Patient Safety

apparent that hospitals spent a greatdeal of time in creating their submis-sions,” says Gary Hutchinson, presidentand CEO of PDC, and a member of theJudging Committee. “The stories werevery detailed in conveying the develop-ments of patient safety programs, com-plete from arduous beginnings tosuccessful outcomes. Overall, entrantswere centered on methods such asadvanced technologies, patient identifi-cation, staff education, and communi-cation. But what we found mostpoignant in the entries was the incor-poration of the involvement of patients,community, and volunteers as part ofsystematic approaches to patient safetyprograms and goals.”

Susan Carr, editor of PSQH andalso a member of the JudgingCommittee said, “The contest offereda unique opportunity to see how hos-pitals are truly making a difference inpatient safety. The entries representeda variety of approaches to technology,staff training, and system improve-ments across different clinical areas.In judging the entries, we paid atten-tion to effective implementation aswell as the methods hospitals used tomeasure, evaluate, and sustain theirprograms.”

“PDC along with PSQH is veryproud to recognize the winners of thePatient Safety Success Story contest.These are truly outstanding stories ofhospitals improving patient safety andcare. They demonstrate that the ulti-mate winners are the patients,” addsHutchinson.

First PrizeParkview Medical CenterPueblo, ColoradoSafety at the Bedside: Handheld

Technology to Improve MedicationAdministration

Eileen Dennis, RNChief Nursing Officer

HonoreesHoly Spirit Hospital on behalf of

the Color of Safety Task ForceCamp Hill, PennsylvaniaBanding Together for Patient Safety:

Alert-Band StandardizationFranchesca J. Charney, RNDirector of Risk Management/

Patient Safety

Lutheran Medical CenterBrooklyn, New YorkUpgrading Infusion Pumps

System-wide: Alerts, Libraries,and Protocols

Rosanne Raso, RNSenior Vice President of Nursing

Services

UPMC Presbyterian ShadysidePittsburgh, PennsylvaniaTicket to Ride Program: Providing

Safe Intra-hospital TransportDarlene Lovasik, RNAdvanced Practice Nurse

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November/December 2008 ■ Patient Safety & Qual i ty Healthcare 15

AcknowledgementsJudgesGary HutchinsonPresident & CEOPrecision Dynamics Corporation

Susan CarrEditor and Associate PublisherPatient Safety & Quality Healthcare

Tamara R. Chandler, BSN, RN, JDDirector of Patient SafetyAdvocate Good Samaritan HospitalDowners Grove, Illinois

Maggie Lohnes, RN, CPHIMS,FHIMSS

Administrator, Clinical InformationManagement

MultiCare Health SystemTacoma, Washington

Judge’s Review CommitteeNick CurtinScott HirstDaniel HobinAdrienne S. Lamm

Special ThanksChuck HughesLeona ChavezMarvin DiamondLinda Gonzalez

First PrizeSafety at the Bedside:Handheld Technology toImprove MedicationAdministrationParkview Medical Center is committedto supporting its nurses in their efforts toinsure that medications are administeredto patients as safely and effectively aspossible. In 2005, Parkview paid particu-lar attention to this issue and convened amultidisciplinary medication adminis-tration team with representation frompharmacy, nursing, information sys-tems, and administration. As the teamdiscussed the medication process, itbegan to focus on a Zen-like realizationthat ultimately led them to the improve-ment implementation for which theyhave won this year’s Partner in Patient

Safety contest. The realization was that“you don’t know what you don’t know,”or to paraphrase the final question fromthe October 7 presidential debate, theteam wondered, “What don’t nursesknow and how will they learn it?”

The team recognized that the lastchance to stop a medication error isat the bedside, but the nurse at thebedside, at the “sharp end” of care,about to administer medication to apatient, had no way to know if anerror had occurred earlier in the pro-cess. Eileen Dennis, chief nursingofficer at Parkview, identified impor-tant questions that nurses often can’tanswer at the bedside: “Has the drugbeen transcribed correctly? Has itbeen discontinued recently? Has themedication packaging been correctlylabeled? Is the dosage correct? Havenew medications been ordered forthis patient that I’m not unaware of?The possibilities are endless.” Theteam shared the nurses’ fear of notknowing how many medicationerrors were occurring. Further, theteam realized that a good tracking

mechanism would help solve thisproblem and that technology wouldhave to be part of the solution.

To address this weak point in theprocess, Parkview Medical Centerimplemented a barcode point-of-caresolution designed to eliminate medi-cation administration errors. Thesystem uses a relatively small, hand-held device that nurses carry withthem during their entire shift. Thedevice is linked wirelessly to the phar-macy. When a nurse scans a patient’swristband, the device displays accu-rate up-to-date medicationinformation for the patient, as well asreminders to ensure the Five Rights:right patient, right drug, right dose,right route, and right time. The devicetracks all medications for patientsassigned to each nurse. It alerts thenurse when doses are due and whenmedication orders have been added ordiscontinued. It also prompts thenurse to document data such as painscales and vital signs for each patient.

Beyond ensuring the accuracy andsafety of medication administration at

Nurses at Parkview Medical Center use a wireless handheld system to assist in compliance of the five rights of

medication administration.

Photo by John Recor

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the bedside, the team anticipated thatthe technology could improve otheraspects of the work environment fornurses. With increased confidence thatmedications were being managed,administered, and documented correct-ly, confidence would improve, enhanc-ing the hospital’s culture of safety andblame-free environment. In addition,the team hoped that the tool wouldhelp nurses improve their organization-al and time management skills.

Weaknesses in Original SystemBefore Parkview implemented thehandheld system, medication adminis-tration began when the unit secretaryreceived a medication order from aphysician, transcribed it, and scanned itto the pharmacy, where it was profiled.Nurses verified orders by signing offmedication administration records(MARs) that were handwritten by theunit secretary. The pharmacy printed,updated, and distributed the MAR. Inaddition, at midnight, the pharmacywould print reconciliation sheets,which nurses used to retrospectivelyidentify MAR errors. That was the firstopportunity the nurse had to verify thatthe medication had been profiled cor-rectly, though several doses of the drugmight have already been given.

This system posed many challenges:• The turnaround time for pro-

filing an order often was unac-ceptable.

• A lack of communication andunderstanding between nursingand pharmacy sometimes led tofinger pointing.

• All checks and balances weremanual, and it could take hours,days, or weeks to track down amedication discrepancy.

• There was no easy way to closethe documentation loop for pain scale, high profile meds,patches etc.

Parkview saw immediate improve-ment in medication errors shortly afternurses started using the handheld sys-tem. Prior to implementation, Parkview

conducted a study of medication errorusing a landmark study by Barker et al.(2002) as a guideline. Through nurseobservation, 250 medication doses weremonitored. The pre-implementationstudy found that 20% of the doses hadan associated error. The biggest per-centage of error (18%) involved medi-cations given at the wrong time. Thisdata was in line with the Barker et al.study, which reported 19% total errors.Parkview repeated the study afterimplementation of the handheld sys-tem and found that the total error ratehad dropped to 8%. The data alsoshowed that prior to implementation,97% of nurses failed to use two identi-fiers before administering medication,and 85% did not record clinical obser-vations on the MAR. Post implementa-tion, 100% of nurses checked twoidentifiers, and 100% recorded clinicalobservations on the MAR.

Further Improvements to the SystemThe results showed definite improve-ment, which was very encouraging, butParkview’s leadership felt there weremore gains to be made. They knew thatany technology must be used correctlyand consistently to yield its full bene-fits. Through continuous education,ongoing innovation, and administra-tive support, Parkview has achievedadditional improvements from thetechnology used to improve medica-tion administration.

Nursing leadership at Parkviewknew that waiting until midnight to ret-rospectively reconcile MARs was errorprone. They asked the technology ven-dor to work with them to create a wayfor nurses to verify medications in realtime. A new software module for thehandheld system was implemented in2006, which has added another layer ofsafety to medication administration. Infact, over a 12-month period, quaran-tined orders (orders with an error ordiscrepancy) dropped from 1.3% to0.8%. Because of the success ofParkview’s innovation and collabora-tion with Parkview, the vendor nowoffers this module to its customers.

The system requires compliance fordocumentation of pain scales, high-profile medications that need a witnessbefore administration, omission ofmedications, and tracking of patchplacement sites and labs. These were allthings that Parkview had struggled tosolve before using the handheld system.During the first 19 months of imple-mentation, data was collected to ensurethat all medication administration doc-umentation was completed at the bed-side. The compliance rate climbed from70% to a high of 96%.

The pharmacy turnaround time forprofiling a new medication orderdropped from 45 to 15 minutes.

In the past, nurses could overridePyxis to gain access to an override list ofmedications; overrides were significantlyreduced with the new medicationadministration process. Currently weutilize a very small override list thatspeaks strictly to emergent patient needs.If nurses receive the "No order found”message, they are expected to researchthe problem instead of overriding thealert. Data shows that during 5 monthsof data collection, overrides droppedfrom nearly 3% to under 0.5%.

Another advantage of the new med-ication administration system is that itprovides a solid audit trail. In the past,medication discrepancies were difficultif not impossible to reconcile; now theyare easily resolved. The system helpsidentify fraud and ensures accuratebilling from Pyxis.

The handheld technology is basedon barcoding. Barcode scanningaccompanies the administration of allmedications. Witness scanning isrequired with insulin and heparin dos-ing. This technology provides safety atmany levels. All patients have barcodedwristbands, and all medications are dis-pensed in unit doses with barcodes. Allsyringes have barcoded labels withname and strength of medication.Look-alike sound-alike medications areclearly identified.Auxiliary labels flag allmedications that contain odd strengths.

An unexpected benefit of the new sys-tem is improved time keeping foremployee attendance. The nurse’s name

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Barker, K. N., Flynn, E. A., Pepper, G. A., Bates,

D. W., & Mikeal, R. L. (2002). Medication

errors observed in 36 health care facilities.

Archives of Internal Medicine, 162, 1897-

1903.

Parkview Medical Center uses the CAREt

system from IntelliDOT for bedside medica-

tion administration.

REFERENCES

TECHNOLOGY OVERVIEW

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badge contains a barcode that allowsthem access to the handheld system.They must have their name badge inorder to administer medications. Thebadge is also used to swipe in and out ofour time-and-attendance system. In thepast, if a nurse forgot his or her badge, theclock in-and-out times had to be manu-ally edited by the supervisor. Now thename badge is imperative because it linksthe nurse to his or her handheld. Thesedays, nurses rarely forget their namebadges,and editing of the attendance sys-tem has all but disappeared!

And finally, in February of 2007Parkview became an alpha site for thedevelopment of a phlebotomy specimencollection module. In January 2008,Parkview went live with the modulethroughout the facility. Through thehandheld, the module provides real-timeinformation about lab tests ordered for aparticular patient. The phlebotomistscans the armband and immediately hasaccess to all tests currently ordered for

that patient. The handheld also printslabels at the bedside, which the phle-botomist attaches to the specimen beforeleaving the patient’s room. This moduleassures that the correct labs are drawn onthe correct patient,and that they are cor-rectly labeled at the bedside.

Change ManagementCharles F. Kettering once said, “Theworld hates change, and yet it is the onlything that has brought progress.” This iscertainly true at Parkview, where clini-cians have endured many system andcultural changes over the years and havelearned that consistency, persistence, andthe ability to stay the course lead to suc-cess. Such was the case with improve-ments to the medication administrationprocess. Some nurses embraced the newsystem and technology from the begin-ning. They recognized its value and wel-comed the new tool. Most experiencedsome trepidation. Many nurses were notcomputer literate, and the learning curve

was daunting to them. There was anxietyand job dissatisfaction related to the useof the handheld.

Nurses complained of a loss of con-trol over certain aspects of the work envi-ronment. A handful of nurses admittedup front that they just were not up for thechallenge and chose to quit their jobs andmove on to other facilities. Parkviewleadership responded to all of these needsby providing a hotline that is available24/7. The nurses who eagerly acceptedthe new system became trainers andcheerleaders. They were available on thefloor especially during the implementa-tion stage for each unit.

A few nurses did their best to workaround the technology in an effort tocontinue doing what they had alwaysdone. The checks and balances of thesystem, however, quickly identifiedthese people. Senior administrationdemonstrated their support by writinga discipline policy for nurses who sub-vert the new process. Actions can rangefrom counseling and more educationall the way to immediate dismissal.

It has been 3 years since the firstnursing unit went live with the new sys-tem. We have come a long way and areproud to report that compliance withour use of the new system for medica-tion administration is 98%.

The next step is to roll the systemout to the critical care areas. In addi-tion, at the request of our surgicaland emergency department clini-cians, we are evaluating the appropri-ateness of this technology in theirareas as well. ❙PSQH

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