Pursuing Perfection: Report from McLeod on Improving Medication Safety

The Problem: Like most US hospitals, McLeod Regional Medical Center (Florence, South Carolina, USA) had a clear error-reporting protocol. But the actual reporting of errors was far from robust. “The errors we knew about were of small consequence,” says Marie Segars, McLeod’s Vice President of Patient Services. “Most serious errors weren’t getting recognized.”

 

Segars and McLeod’s leaders were uncomfortable simply responding to complaints and concerns about errors after the fact. They wanted to prevent them. They began by focusing on medication errors.

 
The Background: McLeod Regional Medical Center, part of McLeod Health, is a large acute-care hospital serving 12 counties with a population of close to one million. In 1997, McLeod established a Medication Safety Committee whose goal was to reduce the possibility for human error while improving the process of medication administration.
 
The committee was already making progress when McLeod was selected to join Pursuing Perfection in 2001. Pursuing Perfection offered a renewed commitment, and a sharper focus on implementing medication safety improvements. 
 
The Investigation: In 2001, McLeod’s safety leaders examined 220 random medical records to try to quantify the extent of medication errors at McLeod. The data they gathered revealed 61 adverse drug events (ADEs) and a rate of ADEs causing harm to patients in the hospital per 1,000 doses] of 3.5. While this rate was in the lower range of the national average rate of 2 to 8 ADEs per 1,000 doses, McLeod’s safety leaders knew the hospital could do better. 
 
“It was like peeling an onion,” explains Segars, “and we had already taken off the outer layers by fixing the easy things.” Now, she says, they knew it was time to redouble their efforts and make a bigger difference.
 
The Solution: McLeod made a strong commitment to medication safety from the very top of the organization down. “We developed a vision for medication safety,” says Segars. That vision calls for perfection of the medication delivery system to be safe for every patient, every time, while making it easier for caregivers to do the right thing, and impossible to do the wrong thing.
 
Photo_McLeodCEORobertColones.jpg 
McLeod CEO Robert Colones greets a
patient during daily patient rounds.
 
McLeod’s safety leaders formed dozens of teams and launched literally hundreds of new initiatives aimed at improving medication safety. Some of these were small — new forms and reports, for example, and separating drugs that look alike and sound alike — but many were significant — such as increasing physicians’ use of hand-held computers for medication tracking. Three years later, McLeod has instituted several new systems and changed many of the hospital’s ways of delivering care. 
 
Culture ChangeHaving spent years working to change the culture of “blame and shame” through training and education, McLeod introduced executive safety rounds, in which senior leaders regularly visit patient care areas to listen and learn about barriers to safety from front-line staff. At first these rounds were conducted bi-weekly or weekly; now, they’re a daily occurrence. As a result, says Segars, “We got very comfortable talking about our own errors.” The number of reported errors began to climb, providing richer opportunities to learn where the system was weak.
 
Computerized Medication OrderingMcLeod’s leaders knew that technology could play a critical role in improving medication safety, and they committed the necessary funding and training resources to support it. They implemented a computerized medication ordering system, reducing opportunities for errors due to handwritten prescriptions, and increasing opportunities to identify potentially harmful drug interactions before prescriptions are filled.
 
Medication Administration Checker: More cutting-edge still, in 2003 McLeod decided to employ a Medication Administration Checker (MAC). This bedside technology enables nurses to scan bar codes on their own armbands, the patients’ armbands, and the medication itself to verify that the correct medication, dosage, route, time, and patient have been selected before the medication is administered.
 
“In the first week of using MAC, the system caught about 40 instances where a mistake would have been made, and most likely would never have been detected,” says McLeod’s Marie Segars.
 
Automated Medication Dispensing: Automated dispensing of medications was also introduced on the med/surg units. Like vending machines, the Pyxis MedStations on each unit dispense the medications physicians order after the pharmacy verifies and releases them. The medications most typically used on each unit are stocked in the machine, saving time for both nurses and pharmacists.
 
Decentralized Pharmacists: In addition, pharmacists have been decentralized and made more accessible throughout the hospital. They’re now deployed to patient care floors with cordless phones where they’re readily available to consult with physicians, nurses, and patients.
 
The Real Bottom Line: McLeod’s leaders decided to use IHI’s Trigger Tool for Measuring Adverse Drug Events to dig even deeper into their medication error data. “What we really want to get at is not just errors, but harm,” says Susan Muench, McLeod’s Director of Clinical Outcomes and Medication Safety Team member.
 
The tool helps to categorize medication errors according to nine levels of harm, from an error that has the capacity to cause harm but that does not reach the patient all the way to an error that results in death. Errors rated A through D — those that did not cause harm to the patient — are tracked, trends are noted, and improvements introduced as needed. Any error that is an “E” or greater, meaning that the error caused harm, receives special attention.
 
“It’s the errors that have contributed to or resulted in temporary harm to a patient that really require intervention,” she says. “That’s where our rate of harm stems from. Those are the errors around which we form teams and create process improvement initiatives.”
 
The Results: The combination of technology and process improvement work have helped McLeod reduce from 17 to 5 the number of steps required from ordering to administering medications to patients. The average wait time for patients to receive medication has dropped from 92 minutes to seven.
 
The rate of ADEs causing harm to patients in the hospital, higher than two per 1,000 doses during 2002, began to drop in 2003, and was less than one for at least half of 2004.
 
What the Team Members Said: “It is important to us to have a sense of urgency about this work. Terrible mistakes can happen, and we have a sense of urgency about understanding why, being open about those mistakes. We’ve made a lot of progress, but there is still plenty of work to be done.” — Marie Segars, Vice President of Patient Safety
 
“The medication safety work has been very energizing for staff. The dynamics of the medication safety team are extraordinary, and the commitment of employees to patient safety is pretty impressive. They really want to make a difference, and through this work they know they can.” — Susan Muench, Director of Clinical Outcomes, Medical Safety Team Member
 
Learn More about McLeod Regional Medical Center:
 
Listen to what Donna Isgett, Vice President for Clinical Effectiveness, says about McLeod’s determination to “raise the bar” in these three audio clips:
 
Pursuing Perfection hospitals enjoy a health competition
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Vigilance around evidence-based care is central to "raising the bar"
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McLeod wants to become the safest surgical hospital in the US
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