CNL - Improving Medication Administration in the Outpatient Setting

UNIVERSITY OF SAN FRANCISCO CNL ONLINE PROGRAM PROSPECTUS SUMMARY BRIEF IMPROVING MEDICATION ADMINISTRATION IN THE OUTPATIENT SETTING SPECIFIC AIM: WE AIM TO IMPROVE THE MEDICATION ADMI

UNIVERSITY OF SAN FRANCISCO CNL ONLINE PROGRAM PROSPECTUS SUMMARY BRIEF IMPROVING MEDICATION ADMINISTRATION IN THE OUTPATIENT SETTING SPECIFIC AIM:

WE AIM TO IMPROVE THE MEDICATION ADMINISTRATION PROCESS AND INVOLVE ALL STAFF WITHIN 6 MONTHS

AUTHOR: Savannah M Klinginsmith, RN

BACKGROUND:

The microsystem consists of 14 for-profit outpatient family practice and urgent care

combination clinics that provide convenient, accessible, and quality care within 7 communities with over 200,000 visits annually Each clinic staff consists of an office administrator, a family practice physician and urgent care provider (MD, DO, NP, or PA), 2-3 front office clerical staff, and 3-5 back office staff (RNs, LPNs, MAs and RTRs) A couple clinics are larger with an

additional 2-10 staff for front and back office The management of all clinics is off-site at the administration office, where company directors, billing, and nursing leadership work

During new employee training (bi-monthly) and spot checking of new hire charts in 2013 into summer of 2014, it was recognized that many staff are unfamiliar with medication calculations and appropriate documentation of medication administration A review of medication

administration process was recommended by the nurse trainer and supported by the nursing director During chart reviews, it was noted that many steps of documentation were routinely missed, which led to suspected medication administration errors

SUPPORTIVE DATA:

In August and September 2014, a FMEA was completed after direct observation of nursing staff

by the CNL student during the medication administration process The estimated number of medications administered (immunizations included) across the 14 clinics are 400-600 per day The process map (Appendix A) demonstrates steps for best practices in medication

administration Data obtained by the CNL student resulted in the discovery of several faulty steps in the process of medication administration The faulty steps are indicated by green boxes

on the process map A key concern is the actual process of a verbal order given to the staff, then changed during provider documentation, but after the medication is administered This failure is associated with the verification of the medical record prior to administration In addition, coding audits indirectly show documentation errors The data is evidence of the failures leading to unsafe medication administration practices This project is considered proactive in preventing medication errors

MICROSYSTEM SATUS RELATIVE TO THE PROJECT:

A SWOT analysis (Appendix C) shows a need for the project, as the identified weaknesses and threats contribute to potential medication errors, quality and safety of patient care, and risk and liability Support from the Clinical Director and the Back Office Team

(a group of office managers designated to work on nursing staff process, workflow, and

improvement processes), along with long-term staff and a limited number of medications are strengths for project development Implementation of the project would provide opportunities for additional project developments in medication safety, such as detailed policies, open

additional communication channels for staff and nursing leadership, and encourage staff to share their ideas and education topics for future projects

SEARCH STRATEGIES:

The references utilized for the project support improving medication administration process and protocol in the outpatient setting Articles chosen range from 2011 to 2014 and provide

guidance for the project

DATABASES USED:

Searches were done through Google Scholar and CINHL

SUMMARY OF EVIDENCE:

Abramson et al (2012) supports that the recognition of medication errors in the outpatient setting assists in improvement strategies for medication safety through provider order

clarification, as many errors are related to the prescribing process According to Abramson et al, staff and providers are to communicate if changes or questions arise prior to medication

administration

Bernstein et al (2011) explains the statistics for medication errors across the nation in relation to medication reconciliation, including all aspects in which errors occur The authors’ purpose shows how plan implementation of medication reconciliation improvement, physician order clarification, and follow up calls to patients contributes to patient safety and improves care

Mehndiratta (2012) concludes that medication errors in outpatient settings are not uncommon Mehndiratta’s purpose is to indicate there are strategies, such as having the latest medication reference available, standardized medication measuring products (oral syringes most accurate), education for an understanding of accurate medication calculation, dosing and reconstitution, and improving communication of healthcare providers and patients can be implemented to improve medication dispensing and administration processes

Neuss (2013) explains that competency and knowledge of the medication for oral

chemotherapy is essential in promoting safe medication administration In addition, the author

concludes that the development and implementation of safe processes and protocols will improve the safety of medication administration

THEORETICAL FRAMEWORK:

Objectives and changes anticipated based on implementation of the project is to engage staff in support for improving medication administration standard of care based on national initiatives Engaging participation and input from staff fosters team collaboration and promotes buy-in Ideas from staff, along with the education on medication administration practices and process map posters will provide additional knowledge and opportunity for questions Collaboration facilitates a common goal of improving patient care

STAKEHOLDERS:

Company stakeholders consist of the Director of Clinical Services, Director of Operations,

company president, medical management committee, the back office team, clinic

administrators, nursing leadership, patients, and nursing staff (nursing staff consist of RNs, LPNs, Medical Assistants, and Radiology Technologists) Project approval process is based on the value of the project in relation to patient care, priority level, and resources required for

implementation and ongoing project maintenance Project approval by the stakeholders is needed prior to implementation While the stakeholders value patient safety, the recognition of limited resources and competing priorities results in the project having limited support at this time Evidence from the stakeholders at the institution and the SWOT analysis direct this project The plan for improvement can proceed in the absence of a concrete timeline

APPLY THE EVIDENCE:

National initiatives focus on decreasing medication errors to improve patient safety and reduce harm Congress mandated the Institute of Medicine (IOM) to “carry out a comprehensive study

of drug safety and quality issues in order to provide a blueprint for system-wide change” (IOM, 2003)

System failures in the medication administration process are identified in green on the process map In accordance with Bernsteins et al’s (2011) quality improvement, staff education in medication adherence, patients’ knowledge of medications, and knowing the patient’s current history and medications will increase accuracy in medication administration In addition, the IOM’s Preventing Medication Errors: Quality Chasm Series (2007) signifies medication errors are high Strategies for quality improvement through process changes do reduce the risk and number of errors

BUISNESS CASE:

Implementation costs for the project include staff education, poster for each clinic, and planning

of the project by the CNL The cost of training will be better figured when the number of staff

needing to be trained is determined The nursing staff and estimated training time is 4-6 hours over the course of 6 months The average staff hourly rate range is $16-$22/hour (staffing consists of: Medical Assistants, Licensed Practical Nurses, Registered Nurses, and Radiology Technologists) The CNLs time in planning the project is 220 hours thus far, and is anticipated to have another 40-60 hours for implementation

Medication errors are costly The Institute of Medicine’s report, To Err is Human: Building a Safer Health System, states that medication-related errors were a significant cause of morbidity and mortality and were estimated at more than 7,000 deaths annually (Hughes and Blegen, nd) The Network for Excellence in Health Innovation (NEHI) estimate 16.4 billion dollars of

preventable medication errors occur in the outpatient setting annually

STEPS FOR IMPLEMENTATION:

Through utilization and implementation of the process map by staff, evidence based practice would be initiated for process improvement and decreased medication errors

Implementation planning includes:

 Medication administration baseline audit

 Staff education – steps of medication administration via email

 Staff drop box for monthly medication administration education topics for staff input and buy-in for a medication process improvement campaign

 Medication protocol development & revision

 Protocol poster

 Process poster with halt steps

 Process and timeline for implementation presented to Back Office Team and Director

 Clinic Administrator notification and project plan training

SUPPORTIVE THEORY:

Lewin’s 3 Step Change Theory will be applied for the project, utilizing the unfreeze, transition, and freeze stages The unfreeze stage is presenting the project to the staff along with the rationale for the change This will assist in buy in and additional ideas The second phase, transition, will be during the implementation of the project and working towards developing new attitudes and behaviors for safe medication administration The final stage, or freeze, is acceptance of the new protocol and routine practice of the protocol

TIMELINE OF ACTIVITIES INCLUDING EVALUATION METHODS:

After plan approval by the stakeholders, implementation will occur over six months The

timeline (Appendix D) begins with an initial medication documentation audit and staff education via email During month’s two through six, additional email education on medication best practices will be sent to staff once a month and the medication process poster will be posted at

each medication preparation area In addition, during month two, a staff survey will be

completed asking for ideas to improve the medication administration process The initial chart audit is to be compared to a secondary audit in six months to evaluate the effectiveness of staff education over the six months

RESULTS/OUTCOMES:

The results of the FMEA show data supporting the need for the project Research and planning for the project has occurred with a plan for implementation Due to other projects of higher priority, the project is on hold The project timeline is to be adjusted to account for delays and

be applied when feasibility for the project is available A review of the project proposal was completed with the Director of Clinical Services again, with more detail, and interest for the project was shown Further discussion is to commence after the first of the year Based on the evidence, strategies for project implementation will improve quality patient care, work towards the national initiatives for decreasing medication errors, and decrease risk and liability

RECOMMENDATIONS:

To date, a protocol has been developed based on evidence The timeline has been altered to consider the need for flexibility in the microsystem Continuing to be proactive in improving medication safety through collaboration with the back office team for a feasible timeline and implementation methods is recommended for improving medication safety The

recommendation is to continue with the project and plan for staff education and then

reevaluation as indicated by the specific aim and plan

Appendix A: Process Map – Steps of medication administration

Process map with ‘halt’ flags for posters

Appendix B: Fishbone Diagram

Appendix C – SWOT Analysis

 Supportive Managers & Directors

 Long term staff in clinic setting (strong

knowledge base)

 Consistent medication type in each

clinic

 Limited number of medication options

(20)

 Small company

 Desire for patient safety

 Limited staff (administrative & nursing) resources

 Limited time/focus – too many projects

at the same time

 Variation in clinic set-up; confusing staff

 Medication prep area is at the nurses station

 Additional support for

change/improvement

 Detailed policies

 Communication channels through

established monthly meetings & email

 Variation in staff license, training and scope of practice

 Busy (10 patients at the same time, phone calls)

 Emergencies

Appendix: D Projected Timeline

Appendix E: Medication Administration Protocol

Medication Administration Protocol

For all medications:

1 Make sure there is an order in the Treatment plan (For Injection only visits, see

Testosterone/Vitamin B-12 or other injection only visit on page 2.)

a Verification of a medication order is essential in preventing a medication error

2 If you are administering one of the UC approved medications, verify ALL Current

Medications (not just the medication to be administered) and pull them into the

progress note Include the dose, route, frequency, and duration Then follow steps 3

through 9

3 Review the 8 rights of medication administration (see below) Check your medication vial 3 times; compare with order

a Right patient, medication, dose, route, time, documentation, reason/rationale for medication, and response/desired effect

4 If giving an injection (except vaccines), get a consent Time stamp and then document the information that goes along with the consent Scan into patients chart

5 Document the correct medication and dosage (If the provider has not entered an order, verify order with provider, time stamp and indicate that a verbal order was given and by whom)

a (Repeat verbal order back to clarify and confirm order, med, and dose, prior to administration.)

6 Time stamp Administered by: and record the lot #, expiration date, and NDC#.

7 Document the correct site and route.

8 Have the patient wait 15 minutes to observe for any adverse reactions or for efficacy of

the medication ***Go back to the procedure and time stamp –checked by: and choose the option for reaction or pain relief (This must be done even if you are not the person

who gave the injection.)

9 Make sure you have billed for the medication with the appropriate number of units and the administration

Notes

If your ‘Administered by’ time stamp time does not reflect the exact time that you gave the

medication, then time stamp and type “Medication given at approximately .” Similarly, if your

‘Checked by’ time stamp does not reflect the 15 minute wait, then time stamp and type “Patient

left after 15 minutes with no reaction” or “Patient left at approximately _ with no adverse reaction.”

Depo-Provera

*If you are giving Depo-Provera at an AB nurse visit make sure there is a standing order Verify

ALL Current Medications (not just the medication to be administered) and pull them into the progress note with the dose, route, frequency and duration Go to the HPI then OB/GYN then

Depo-Provera Choose the appropriate data Take the patient’s vitals and then go to

Procedures, then Medication Administration, and complete steps 1 through 9.

Testosterone/Vitamin B-12 or other injection only visit

1 Make note in the chief complaint for injection only visits (see example below) regarding the order referenced The patients chart should always be checked, at each visit, for a current order that includes: the medication to be given, the diagnosis, frequency, length

of time (including duration), ordering provider’s signature, and a current consent