Magazine article Drug Topics

Hospitals Snag Safety Award for Revamping Drug System

Magazine article Drug Topics

Hospitals Snag Safety Award for Revamping Drug System

Article excerpt


Last month, Legacy Health System received the Ernest T. Livingstone award in recognition of its latest move to increase patient safety. Legacy, a Portland, Ore., group of four hospitals, was chosen for the award after conducting a pilot study of a new medication distribution system.

Legacy's new system encompasses all aspects related to medication-from ordering and dispensing to administration and documentation. Legacy got the idea to reengineer its system about two years ago, said Kathy Stoner, Pharm.D., director of pharmacy.

Data on errors had been collected for all four hospitals. A medication observation study found the results comparable to results in the literature, showing the hospitals were performing as well as others across the country. But Legacy wanted to do better. After reviewing the Institute of Medicine's report, "To Err Is Human," Stoner said she and her colleagues found some of the recommendations consistent with their own goals-in particular, standardization of process, systems that complement electronic medical records, and reduction of medication errors consistent with their goals.

Legacy had other goals, as well. Being compliant with regulatory agencies and increasing efficiency were also important, said Stoner. While all four hospitals had the same tools, each had different processes. And the hospitals were not utilizing all of the tools available to them, nor were they consistent.

In early 2001, Legacy set up a multidisciplinary team of representatives from administration, nursing, pharmacy, and quality control. The team was named MODAD (for medication ordering, dispensing, administration, and documentation). The team examined the data collected from all areas of the current system and devised a new system to improve the process. The team came up with four. goals for the new system:

* Develop a system of computerized physician order entry (not implemented yet)

* Implement a bedside bar-code system (also not yet implemented)

* Increase pharmacists' involvement in medication use process

* Consistently involve pharmacists in multidisciplinary rounds

A key aspect of the new system is full use of all resources now in the hospitals. "We wanted to rely on the built-in checks we already had in our system," Stoner explained. For example, the team wanted to correct the potential for errors created by nurses pulling drugs from the automated medication dispensing system (AMDS). …

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