Founders 10 members (from left) William Baratta, PharmD; Sheri Walsh, MSN; Catherine Amorose, BSN; Bernadette Tasker, BSN; and Lauren Gebrian, CRNP, at the Omnicell dispenser, a key part of the unit’s medication loop.
Anyone with children knows about interruptions – in the middle of cooking, in the middle of talking on the phone … pretty much any time. While sometimes annoying, these interruptions rarely result in anything serious. But the consequences of losing focus could take a more dangerous turn when the interruption occurs in the hospital during the medication process. Indeed, studies have shown that the severity of medication errors increases with the number of interruptions. Combine this with the fact that medications represent the most common form of treatment and the potential for error increases. “Nurses are doing meds all the time – some patients have up to 20 meds,” said Suzanna Ho, MSN, coordinator of Patient Safety and Quality Nursing. “But it’s natural to interrupt – people don’t think about it.”
Adding to the many medication safety precautions HUP has in place, it recently launched an initiative that provides the tools and education to remind staff that at any stage in the medication process – from prescribing to administering – it’s essential that the clinician stay focused. An interprofessional team – which includes providers, nurses, respiratory therapists, and pharmacists – worked together to develop the initiative. “We talked through the workflow … the challenges that the different disciplines face, which opened a great partnership and communication,” said Betty Ann Boczar, MS, BSN, nursing director of Regulatory Compliance HUP/CPUP. “We gained an appreciation and value of each other’s work when it comes to the different stages of the medication process.”
The initiative also educates about the importance of not interrupting someone who is engaged in the medication process. “It empowers staff to respectfully disengage with others during the medication process without appearing rude,” said Dina Bammer, MSN, a Nursing Professional Development specialist. “This is permission to do so.”
Ho said that feedback from staff, especially Founders 10 and 11, “helped inform the whole process, identifying barriers and ways to overcome them.” The initiative will include standardized education for all staff, including nonclinical employees such as EVS and Transport. It also includes STOP signs in areas that are commonly part of the medication loop on a unit, for example, the med room, or at the medication cart or Omnicell® dispenser. The signs remind staff that “Medication Preparation in Progress. Do Not Disturb.”
Boczar said they plan to integrate the medication safety initiative into CPUP’s outpatient practices as well. “We’ll share what we learned and our tools with CPUP leadership and see how they can best apply to outpatients,” she said, adding that this is especially important in “high-risk areas, such as radiation oncology and chemotherapy,” as well as areas of high volume, such as one-day procedures (like colonoscopies).
“I think it’s even more important on the outpatient side,” Ho said. “Clinicians know inpatients better and are more familiar with their medications. Outpatient encounters are more brief and may have more changes – for example, it’s not always the same chemotherapy.”
This will not be a “one and done” strategy, Boczar stressed. “We plan to embed the education in new-to-practice orientation for nurses and other disciplines, as well as do periodic safety workarounds,” she said. “First we push the culture to change and then we make sure it’s sustained.”