It is widely known that medication errors continue to be one of the most frequent causes of preventable harm in health care and a leading cause of injury and death to hospitalized patients.  According to the Institute for Healthcare Improvement (IHI), poorly communicated medical information at admission and other health care transition points, is responsible for as many as 50% of all medication errors in hospitals.  In an effort to prevent medication errors, the IHI endorsed medication reconciliation as one of the six initiatives in the 5 Million Lives Campaign, and The Joint Commission (TJC) added mediation reconciliation to the 2006 National Patient Safety Goals (NPSG). 
 
Medication Reconciliation, NPSG 8, is an interdisciplinary process between nursing, physicians, and pharmacy which compares the patient's most current list of home medications, including over-the-counter and herbals, against the physician's admission, transfer, or discharge orders.  Discrepancies are brought to the attention of the physician, and if appropriate, changes are made to the orders, thereby decreasing the potential for adverse drug events. Medication reconciliation is truly a collaborative effort.
 
While the significance of medication reconciliation is well known and acknowledged, executing a well-defined process has proved to be a major challenge. Like most hospitals throughout the nation, implementing NPSG 8 has been a difficult journey for us at SJH.  The Joint Commission has received feedback from hospitals throughout the country indicating that NPSG 8 is one of the most challenging requirements to implement.  In fact, in response to concerns about the challenges, TJC will not develop new NPSGs for 2010, but will focus on increasing the value of the existing requirements in helping organizations provide safe, high-quality care.  
 
In the meantime, the Board of Directors at SJH has made medication reconciliation a top priority for 2009.  An interdisciplinary team of dedicated employees at SJH continually strives to evaluate and improve the current medication reconciliation process using the Plan, Do, Study, Act model of improvement.  In an effort to obtain as much feedback as possible from the front end users of the process, the proposed policy has been taken to numerous task forces and committees for review and input.  Input has been sought from individuals at numerous staff meetings as well as from the Medication Safety Committee, Patient Safety Committee, Nursing Quality Council, Division Advisory Committee, Senior Nursing Leadership, Quarterly Medical Staff meeting, Medical Executive Committee and the Discharge Planning Process Improvement workgroup.
 
Compliance with the process is audited on an ongoing basis by the Quality and Resource Management Department, and the results are shared at numerous staff meetings, posted publicly on the Quality Bulletin Board, and shared in the Medical Staff Newsletter.  Some of the indicators include: was the form initiated on admission and present in the medical record, did the form contain unacceptable abbreviations, was the form completed and signed by the physician, and was the form received and reviewed by pharmacy. In doing so, areas in need of improvement are identified.  One of the first issues identified with the admission process was the admitting physician's failure to notice the medication reconciliation form present in the chart.  After much brainstorming and deliberation, the idea of the "Hot Pocket" was voted upon.  After the nurse completes the admitting medication reconciliation form, he or she places it in the bright red folder, AKA "hot pocket", located at the front of the chart.  This prevents the form from getting overlooked and alerts the physician to review and sign the form.  After implementing the hot pocket, compliance with physicians signing the form on admission steadily improved.  The results of the physicians' compliance with completing the process are stored in their quality profiles.
 
After the process for admission was in place and working well, it was time to extend the process to transfer and discharge.  This posed quite a challenge!  Again, numerous meetings were held with representatives from pharmacy, nursing and medicine.  A form to be used at transfer was developed, trialed, and tweaked before it was finally implemented.  Evaluation of the process at transfer has proved to be effective.  Feedback regarding the process is positive, but because there is always room for improvement, the form was recently updated again after receiving some valuable feedback from nursing and from one of the cardiologists.  The nurses in the UAC in the ICU recommended that the transfer medication reconciliation process be followed after a patient is extubated, seeing that all medications need to be reviewed and renewed at this time.  A cardiologist further recommended that in addition to checking off Renew or Discontinue next to each medication, a section be added to Change the medication, similar to the options on the admitting medication reconciliation form.  These proposed changes went to the Division Advisory Committee, Critical Care Committee and Pharmacy and Therapeutics Committee for approval.  They are pending approval by the Medical Executive Committee at present.
 
The biggest challenge regarding medication reconciliation is the process followed at discharge.  This process involves numerous steps with roles assigned to more than one responsible party.  The original form sent home with the patient was felt to be too confusing for a patient to follow and therefore was determined unsafe to go home with the patient.  A new idea was needed. As a result, new discharge forms were developed, with page 2 of the forms dedicated solely to medication. The finalized process, which specifies roles and responsibilities for each step of the process, is currently under discussion and deliberation.  The proposed recommendations are being shared with the VP of Medical Affairs and will be presented at the Medical Executive Committee in July for feedback and approval.  If approved, a major organization wide educational roll out will be planned, with a focus on individualized teaching with appropriate time for questions and answers. 
 
While the current paper process is being reviewed and fine tuned, a group of individuals are working behind the scenes on investigating an electronic software product for medication reconciliation.  Multiple webinars have been held with a company called Meds Tracker and feedback is being sought by front end users as well as information technologists and policy makers behind the scene.  Thus far, subcommittees of the Discharge Process Improvement Workgroup and the Medication Safety Committee have had a telephone conference with two hospitals that currently use Meds Tracker in order to obtain their feedback and experience with its implementation.  The feedback was positive, and the request for purchase of the product appears to be going forward to Senior Management.  
 
Medication reconciliation has indeed taken us on a journey with many uphill struggles along the way.  But we refuse to give up.  We are continuously searching for ways to improve our current process in an effort to improve the care we provide our patients. When we feel like we are in over our heads and will never be able to truly refine the process, we think of the words stated by Donald M. Berwick, MD, MPP, President and CEO, IHI "The names of the patients whose lives we save can never be known.  Our contribution will be what did not happen to them.  And though they are unknown, we will know that mothers and fathers are at graduations and weddings they would have missed, and that grandchildren will know grandparents they might never have known, and holidays will be taken, and work completed and books read, and symphonies heard, and gardens tended, that without our work, would never have been."   

We are up for the challenge and refuse to give up!  

Our Nursing Informatics mission is to design, build, and maintain systems that improve communication among caregivers and enhance the quality of patient care.  The Nursing Informatics department has been actively pursuing this mission with recent projects.
 
One of those projects is the Care Organizer which has gone live on all inpatient units.  Care Organizer replaced the traditional paper kardex with an electronic kardex. Post Go Live audits done by the Nursing Informatics department verify Nursing's proficiency at incorporating Care Organizer into their nursing workflow.  Care Organizer is also the platform for St. Joseph's current project, Admin Rx.
 
Admin Rx is a medication administration system, involving scanning the patient's barcoded wristband as well as the barcode on medication and IVs at the patient's bedside, prior to administering any medication or hanging an IV.  The 1999 Institute of Medicine report To Err Is Human noted that point-of-care bar coding offers a simple way to ensure that the identity and dose of the drug are as prescribed, that the drug is being given to the right patient, and that all of the steps in the dispensing and administration processes are checked for timeliness and accuracy.  Once a unit goes live on Admin Rx, the paper MAR on that unit will be replaced with an electronic MAR.
 
The Admin Rx project is a combined effort between Nursing, Pharmacy, Respiratory Therapy and IS.  Over the next six months, much of the Nursing Informatics Departments' focus will be on building and implementing Admin Rx.  In late May, McKesson (The Admin RX Software vendor) was onsite to assist for the Admin Rx Kickoff and Process Design Workshop.  All Inpatient Nursing units and Oncology Infusion Center, as well as Pharmacy and RT had representation at this three day workshop. Input from all these areas will continue to be essential throughout the entire build of Admin Rx.   
 
There will be phased in Go Live Dates for the Admin Rx Project.  The Tentative Go Live Date for 3 North, 3 South, 4 North and ICU will be October 27, 2009. The Tentative Go Live Date for MCH, Rehab, SAMHU, RT and Oncology Infusion Center will be March 1, 2010.
 
More mobile devices are needed to support Admin Rx. A review and evaluation of mobile devices is ongoing. Nursing Informatics is very excited about working with an Admin Rx Design Team to design, build, and implement a medication administration system that will transform clinical practice and enhance the quality of patient care at St. Joseph Hospital.
 
Please visit Nursing Informatics on The Daily Joe Intranet Page for more information about Nursing Informatics at St. Joseph Hospital.
 
Nursing Informatics Department
Dianne Bolton MS, MBA, RN, Director, Ext. 63527
Carolyn Gatchell BSN, RN, Clinical Manager, Ext. 63520
Lisa Rawnsley LPN, NI Education Coordinator, Ext. 63519
Maureen Peters BSN, RN Clinical Application Specialist, Ext. 63530

Calling all Physicians!

Up-to-Date St. Joseph Hospital Construction/Renovation News

St. Joseph Hospital is always looking for ways to improve our appearance and  efficiencies.  The following projects are currently underway or slated to begin very soon.  

• Hudson Medical office building construction is well underway - expect completion this winter.  
• New cardiac catheterization lab installation is complete. 
• Renovations within the main hospital laboratory are near completion.    
• Renovations will begin in Milford ED reception area this fall.
• Construction of a breast MRI reading room will begin this fall.
• Renovations will begin on maternal child health nurses station this summer.
• The Cafeteria on the ground floor at St. Joe's will be renovated - expect completion by the end of August.    

Souhegan Home & Hospice Care is now St. Joseph Home & Hospice Care