Michael Craig, Senior Vice President of Medical Affairs
Tim Collins, Vice President of Quality Management
Deb Fearing, PharmD
Vicky Barnthouse, Director of Nursing
MariBeth Derringer, Director of Quality Management

Decrease the Risk Priority Number (RPN) of the medication dispensing system on one patient care unit by 50 percent from baseline.

Risk Priority Number (RPN), calculated monthly from Failure Modes and Effects Analysis (FMEA)

As we tested changes to our medication dispensing process, we re-calculated the estimated RPN that would result from the change, to see if it would be an improvement. We reported our RPN monthly and re-calculated it each time we moved from testing to implementation of a change, which allowed the team to monitor our progress.

• Changed the process for Medication Administration Record (MAR) stickers, by having the pharmacy technician place these directly in the patient’s file during hourly deliveries, rather than in a universal container. This saved time for the nurses as they no longer needed to retrieve stickers from the container, especially for new orders, and it eliminated the problem of stickers from the previous shift still being in the patient’s file.
• Worked with attending physicians who serve as preceptors to new resident physicians as we found that many new residents were not making good judgments on medication orders. Preceptors worked more closely with new residents to educate them about medication prescribing and we saw a decrease in these issues.
• Decreased occurrences of nursing staff removing medications from the dispensing machine for more than one patient at a time by producing audit reports from the dispensing machine that were shared with staff on the unit.
• Implemented use of pink bags for sending STAT medication orders to pharmacy. STAT medications were returned in the same pink bag to make the delivery easily visible. This reduced turnaround time to 17 minutes.

Using FMEA, we made several improvements to our medication dispensing process. The change to the MAR label process yielded the largest decrease in RPN, as it reduced the risk of many types of errors. We have also seen the impact through more positive working conditions for our nursing staff as well as increased awareness of the importance the hospital is placing on patient safety, especially medication safety.

• Listen to members of the front-line staff and consider their perspectives when implementing changes that affect their work. The staff often gave us the reasons why things were occurring so we could fix the causes, not just implement a change.
• Audit and reinforce any new changes to see if they are really working. Our audit process allowed us to measure our improvement and show results that indicated that it was worthwhile to have pharmacy technicians taking the additional time to file MAR stickers.
• Expect that other things happening in your organization may impact your ability to spread improvements to other areas. Our team expected to see the changes spread to other teams working on patient safety, but that didn’t happen due to the impact of issues such as changes in unit management, staffing issues, and patient acuity.

MariBeth Derringer
Director of Quality Management
mcderringer@mvh.org