QI Case Study Interview with the nurse Dashia Sampson RN BSN You : Good morning
ID: 344690 • Letter: Q
Question
QI Case Study
Interview with the nurse
Dashia Sampson RN BSN
You: Good morning Dashia. I wonder if you would have a few minutes to speak with me. Russell, the unit charge nurse indicated that you would be a good person to speak to regarding the med pass procedure. The Quality Improvement committee is exploring ways that the process could be improved in an effort to decrease the medication error rate and improve the efficiency of the process.
Dashia: That sounds great. I have had some concerns about the number of errors myself and am always interested in thinking about ways that we could work more efficiently.
You: Why don’t we start by having you walk through how a typical med pass works for you?
Dashia: I start out by setting up my medications in the medication room at about 6:30 AM, shortly after I get report. I make sure that everything is stocked on the cart that I might need for the day. It sure is crowded back there, with three of us trying to maneuver around those big clunky medication carts at the same time.
Once we push that cart outside of the medication room, that’s when the interruptions start. If we aren’t trying to answer call lights, we are answering questions for the nurse aides, physicians and families. I manage to get medications passed to about the first two rooms and then it seems like Dr. Burleson is here to make rounds on his patients. That means it is time to lock up the medication cart and make rounds.
About the time I finish with that, breakfast arrives; this is at about 7:30 AM. It gets awfully crowded in the hallway with our medication carts out there and the carts with the breakfast trays on them, so I am in the habit of pushing my medication cart back into the med room when the trays arrive. I help pass breakfast trays and answer call lights until folks get settled in and start eating. Then, it is back to the medication room to pull out my cart again. By that time it is usually about 8:30 AM. The nurse aides continue to have questions for me about providing cares, so I start and stop with the medication administration as many times as I need to. I usually finish up with the morning med pass at about 9:30 AM.
You: It sounds like this is a very busy time for you. There seems to be lots of interruptions and a couple of trips back and forth to the medication room with your cart.
Could you walk through the procedure for actually administering medications to an individual patient?
Dashia: Sure. Once I get into the room I try to find a parking spot that will accommodate my ginormous medication cart. I swear that thing gets bigger every day! Either that or the rooms shrink overnight. Anyway, once I get settled I asked the patient what their name and date of birth is and then I find the corresponding drawer for that room on my med cart. Since the pharmacy provides the medications in the little blister pack, it is easy to check the card with the medication name against the medication administration record that we print out each morning.
Oh, I guess I forgot to mention that I pick up the list of medications for the day from the Health Unit Clerk (HUC) just before I go to the med room to get set up for the morning. Of course after Dr. Burleson makes rounds, I know that I need to go back to the HUC and pick up an updated sheet for any of his patients, in case he wrote new orders. It sure would be nice if they were able to implement the module in NEEHR Perfect where we were able to use a computer to see the medication list and document the medications that we gave right on the computer. Since we are ready use the computers on wheels (COWS) for our charting, I don’t see why we can’t use them for our medications as well. If we did that, as soon as the physician entered the new orders into the EHR, we would automatically have the most up-to-date list of medications. It sure would save some steps and I think it would help with the medication error problem.
Where was I? I guess I was mentioning that we checked the blister pack of medications against the list of meds that the patient is supposed to get. When I’m doing that, I am also checking to make sure that I have the right dose, right route, the right drug and the right time for administration. Just before I give the patient their meds I also check their allergy list and ask them if they have any allergies. I know that they are supposed to have an allergy band on, but half the time what is on the band doesn’t match with what is listed on the med sheet, so I have just about given up on even looking at them. I don’t know what happens to the information between the time it is put into the computer and the time somebody writes out what needs to go on the allergy band, but things sure do get messed up.
You: How much time do you think it takes to pass medications for each patient?
Dashia: It is hard to say, because it seems like everybody has to go to the bathroom when I am in there. Of course I need to get that giant medication cart out of the way, so that means locking it up and putting it out in the hallway. When all is said and done I probably spend 5 to 10 minutes if they don’t have to go to the bathroom and 15 to 20 minutes if they do.
I should mention that there are other things that need to be done surrounding medication pass as well. If someone is on a medication that needs to have specific monitoring associated with it, like a blood pressure or a blood sugar check, then I need to do that as well. Of course the equipment you need never seems to be on the medication cart or in the room, so that means another trip back to the supply room or the medication room, which burns up more time. If a medication requires specific lab work to be checked with that, that means a trip over to the COW to look up the results. There is no room to have both the medication cart and the COW in the room at the same time.
You: The information you provided has been very helpful. Do you have any additional concerns or things that you think I should know about?
Dashia: I notice that when we are short staffed it really makes for an extra crazy day. Weekends seem to be the worst. I wonder if we have more med errors on the weekends. Another thing that I think would be helpful would be some more training on new medications that are coming out on the market. It is kind of scary to be giving medications that you know very little about. I’ll bet Dr. Burleson would be willing to do an in-service on all of the new cardiac drugs.
You: I sure appreciate your time today Dashia. I will be making a report to the Quality Improvement committee and will be sure to include the concerns that you raised in my recommendations. It is great to see that you are so dedicated to making sure that patients are safe.
Using the software of your choice (Word and Visio are two common choices), develop a Swimlane diagram of the process for medication distribution described by Dashia. Capture the major steps involved.
Create a Recommendations section after the Swimlane diagram and do the following:
Describe three (3) recommendations you have, to improve the medication pass. Consider such things as bottlenecks, removing waste, using automation or technology, standardization, equipment, space, staff schedules, etc. While you might have many recommendations, prioritize them to no more than three (3).
Justify the potential impact of the three (3) recommendations you’ve suggested.
Explanation / Answer
Recommendations:
1. Medication list for the day should be ready in advance and when doctor suggests any medication during the day that should be auto updated in the system so that it will be carried on the cart as fast as possible. It can be done through Handset-system automation where doctor would carry mobile device and keeps record of each and every patient and suggest medication. If he feels that the medication to be updated then he should enter a record against that patient and same would be replicated in the backend. This end to end flow would help in reducing back and forth visit to health unit clerk.
2. Since all 3 are working around the cart at the same time, it creates mess and would not fasten the cart preparation. This would be resolved through FIFO process. All 3 should work in sequential manner and be ready with what and when to do next.
3. There should be dedicated time to use bathroom, patient should not use when doctor or nurse are on rounds. This will definately save time.
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