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Health Systems
A
Collaborative Program for Assessing Outpatient Medication Safety: The
KP Mid-Atlantic Region's Experience
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By Ray
Palasik, RPh, MBA; Katherine
A Dunn, RN, MSM; Lizabeth
Taghavi, BS; Susan
Tischler, RN, MSN; Catherine
Dischner, RN, MSN, CEN, CAN; and Curtis
LaFisca, BS
Introduction
Through
the concerted efforts of its Pharmacy Quality, Risk Management, and National
Environmental, Health and Safety/Patient Safety Departments, the Kaiser
Permanente (KP) Mid-Atlantic States Region developed and piloted a program
for assessing safety of outpatient medications delivery systems. The program
is unique to KP in that it addresses, on a national scale, issues of medication
safety in the outpatient setting. To identify issues relating to medication
use, the program uses a systematic approach and an implementation process
that educates and trains staff, leverages known and observed practices
across KP's outpatient medical centers, and provides a mechanism for periodically
measuring improvement of processes and systems.
The assessment
program was designed to achieve the following main goals:
- identify
existing processes and systems susceptible to medication errors in the
outpatient medical centers;
- increase
the use of successful practices in KP's outpatient setting by compiling
known and observed successful practices and then leveraging that information
across the program;
- involve
outpatient medical centers in the process both for their education and
to involve them more fully (create a "sense of ownership")
in patient and medication safety; and
- through
development of self-assessment tools, enable KP Regions to periodically
monitor processes and systems that will result in safer medication use
practices.
Background
and Approach
In early 2001, the KP Mid-Atlantic States Region's Pharmacy Quality
Department, Risk Management Department, and Quality Department partnered
with the National Environmental, Health and Safety/Patient Safety Department
(NEH&S/PS) to develop and pilot a program whose purpose is clearly
stated by the program's name: the Outpatient Medication Safety Assessment
Program. Insight and assistance with developing the assessment program
were provided by the KP California Division: Tools developed for conducting
baseline safety assessment were adapted from inpatient medication safety
assessments completed in California under the auspices of the Garfield
Memorial Fund. These tools also incorporated successful practices described
in the health care literature1-3 as well as information gathered
from other KP programs and initiatives.
The assessment
program is offered regionally and is voluntary. Through an on-the-job
training process, participants gain familiarity with the assessment tools,
share practices, and promote consistency across the assessment program.
The host region invites a pharmacist/nurse team from the next scheduled
region to observe, participate in, and learn the assessment process. These
guests then partner with dedicated national environmental health and safety/patient
safety professionals to conduct the assessment process at a select number
of representative medical centers in their KP Region.
Within three
weeks after the assessment is completed, the KP Region is provided a report
to use for identifying high-priority opportunities and developing a plan
to address those opportunities. Periodic status reports are provided to
the KP Region's Quality Committee to demonstrate progress against open
issues. After completion of all baseline assessments in participating
KP Regions, observed successful practices--a compilation of successful
practices, both from within and outside KP--as well as systems safety
principlesa known to reduce risk will be consolidated and shared
with these regions. Standardized self-assessment tools incorporating successful
practices and systems safety principles--as well as training and educational
materials--will also be provided to assist the regional outpatient centers
with monitoring and maintaining the effectiveness of safe medication practices
and systems.
Scope
of Assessment Program
The assessment program includes five major components: baseline assessment;
compilation of successful practices; enhanced development of self-assessment
tools; dissemination of materials for education and training; and periodic
follow-up assessment.
Baseline
Assessment
Tools are developed and packaged for use in conducting baseline assessments
of the components of outpatient medication safety at KP medical centers:
prescribing, dispensing, preparation, storage, administration, monitoring,
and documentation processes. Assessment at each medical center is generally
conducted over a two-day period and includes review in the pharmacy, medical
records area, ambulatory surgery clinic (if applicable), primary care
and specialty unit examination rooms, medication storage areas, and medication
preparation areas. Staff and management interviews are also conducted,
and although the results of these interviews are shared with the medical
centers, anonymity is maintained to assure open communication.
Baseline
assessment uses six tools:
- The
Pharmacy Inspection Tool is designed to identify current practices
and systems relating to the pharmacy work environment (eg, medication
preparation, handling, storage and dispensing practices) and to assess,
via observation, interaction between pharmacists and patients in the
pharmacy.
- The
Prescriber Practices Tool is designed to address issues relating
to written medication orders (eg, legibility); incomplete or missing
information about dose and its frequency as well as route of administration;
use of qualifying terms (eg, "as needed"); use of overly general
terms (eg, "as directed") instead of giving complete, specific
instructions; use of Latin abbreviations instead of English (eg, using
"QD" or "qd" instead of "daily") to describe
frequency of administration; and proper use of leading and trailing
zeros.
- The
Nursing/Pharmacy Staff Questionnaire solicits anonymous feedback
about the staff's perceptions of medication errors and medication safety
practices within their work environment. Questions pertain to common
types of medication errors; recent medication errors; acceptance of
(or hesitation to accept) reporting errors; occurrence of errors with
drugs frequently reported in medication errors; and what changes in
workplace systems could reduce the number of medication errors.
- The
Management Staff Questionnaire focuses on accountability for medication
errors and reporting as well as accountability for system failures.
Questions focus on implementation of systems for addressing reported
errors or near misses; methods of responding to errors; current medication
error data; regional performance goals or metrics; types of reported
errors and near misses; patient involvement in medication safety processes
and follow-up care.
- The
Unit Assessment and Specialty Area/Cart Assessment Tool is designed
to evaluate the clinical units' equipment and medication storage areas
for cleanliness, arrangement, organization, inventory, and environmental
factors that may affect the
medication safety process. Through observation, interviews, and inventory
analyses, this evaluation process considers availability of current
drug reference material on the nursing units; status of medications
(labeling, dated, expired, location); and use and maintenance of equipment
used in preparing and administering medications.
- The
Medical Record Review Tool is designed to evaluate the format, content,
clarity, and legibility of medication orders written on a patient's
medical record. This evaluation considers accuracy of the medication
order transcription process, quality of documentation regarding medications
administered in the departments, and system components that may increase
the risk of medication errors.
Compilation
of Successful Practices
In addition to identified principles of systems safety, the program
compiles relevant, achievable, successful practices that have been reported
in the medical literature1-3 and observed in KP's outpatient
medical centers. As the program evolves and matures, compilations of successful
practices will continue to grow and be disseminated across KP Regions
in alignment with KP's Patient Safety Knowledge Management Strategy to
continuously improve medication safety.
Enhanced
Development of Self-Assessment Tools
After baseline assessment is completed, each outpatient medical center
is given the opportunity to further use the knowledge gathered from the
assessments (eg, identified successful practices and systems safety principles)
via use of the self-assessment tools. These enhanced tools provide information
to assist the outpatient centers to periodically monitor and measure their
performance around safe medication practices. As later self-assessments
are conducted, awareness of medication errors continually grows and enables
measurement of improvement in both system and process safety.
Dissemination
of Materials for Education and Training
The Outpatient Medication Safety Assessment Program both highlights
and reinforces the training and educational materials created and used
throughout KP--including the "Smart Medication Order" training
conducted in the KP California Division--and shares these materials with
the KP Regions.
Periodic
Follow-up Assessment
Periodically, NEH&S/PS visits KP Regions to help them assess and
improve the medication safety processes and systems implemented after
completion of baseline assessment. This follow-up process supports KP
Regions by supplying resources to objectively assess medication practices
and systems, share successful practices, and highlight innovations in
medication safety.
Assessment
Outcomes
Deliverables Due in 2001
Short-term
deliverables include development and packaging of baseline assessment
tools and known successful practices that outpatient medical centers can
implement to improve medication processes and systems. On-the-job training
will be provided to a nurse manager and to a pharmacy manager. Each participating
medical center will receive a written report of baseline assessment findings
with recommendations for implementing relevant, achievable, successful
practices and systems safety principles. The participating KP Region will
receive a report of compiled recommendations and successful practices
obtained from the baseline assessments. Training and education materials
will be shared.
Deliverables
Due in 2002
A compendium of observed successful practices, successful practices
from the literature, and systems safety principles will be consolidated
and shared after baseline assessments are completed in all participating
KP Regions. Additional materials for training and education will be shared
as they are identified. To periodically monitor implementation of safe
medication practices and systems in all KP Regions, the standardized self-assessment
tool will be delivered and made available. With regional interest and
voluntary commitment to participate, a mechanism for centralized data
collection could enable KP to gather national statistics on safe medication
practices and to measure improvement in these practices and systems in
the outpatient setting.
Deliverables
Due in 2003 and Beyond
NEH&S/PS will be available to conduct periodic third-party assessment
of medication safety and will provide continued information on successful
prac
tices and systems safety principles. Tailored training programs and system
solutions will continue to be identified and developed by NEH&S/PS
in partnership with pharmacy, quality, and risk management departments.
As appropriate, NEH&S/PS will facilitate collection and tracking of
national data on safe medication practices.
Conclusion
As this article went to press, two of four baseline assessment have
been conducted in the KP Mid-Atlantic States Region, and the KP Mid-Atlantic
States Regional Management, Medical Center Administrators, Department
Managers, and staff have overwhelmingly embraced the program. After completion
of baseline assessments at two additional centers in the KP Mid-Atlantic
States Region, the program will be implemented in the KP Ohio and KP Georgia
Regions. Our goal is to implement the program in five KP Regions outside
California by the end of 2001.
a Identified
methods to reduce or eliminate errors where adverse outcomes are possible
but not documented.
Acknowledgments
Doug
Bonacum, MBA, CSP, Director of Kaiser Permanente's National Environmental,
Health & Safety/Patient Safety Department facilitated collaboration
between the Outpatient Medication Assessment Program and the KP California
Division Medication Safety Assessment Program; he also reviewed the article.
Donald Kaplan, PharmD, co-manages the KP California Division Medication
Safety Assessment Program and provided tools we used in the development
of our program. We also thank the many peer reviewers of the program materials.
References
1. Spath P, editor. Error reduction in health care: a systems approach
to improving safety. San Francisco (CA): Jossey-Bass, Chicago: AHA Press;
2000. p 210-1, 218-22.
2 Kiser KW. Patient safety: a call to action: a consensus statement from
the National Quality Forum. Medscape General Med 2001;3(2). Available
on the World Wide Web (accessed June 5, 2001): http://www.medscape.com/Medscape/GeneralMedicine/journal/2001/v03.n02
/mgm0321.01.kize/mgm0321.01.kize-01.html.
3. Types of medication errors, causes, and contributing factors. Briefings
on Patient Safety 2000 Nov;1(11):7.
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