Preventable medication administration errors cost the U.S. healthcare system $21 billion annually, according to a 2010 report from the National Quality Forum National Priorities Partnership. In addition, a 2012 study of community hospitals estimates that each preventable adverse drug event increases costs by $3,511 per patient and increases each length of stay by 3.37 days.
To help avoid these errors, most hospitals have implemented electronic medication administration record (eMAR) systems. While helping nurses work more efficiently, eMARs must be paired with the proper workflow and equipment infrastructure to reap the full benefits. We learned this at Mayo Regional Hospital in Dover-Foxcroft, Maine, during the years after we implemented our eMAR system in 2008.
In our experience, most administration errors decreased after adopting the system, but delays grew. Leadership discovered that with the need to remove one patient set of medication at a time from the dispensing station and the increased time to administer medication with bedside scanning, the electronic medication administration process was creating workflow issues. It was even prompting some nurses to take shortcuts to deliver the medications more efficiently and on time.
After testing and abandoning our new workflow and subsequently investigating best practices, these challenges were resolved with the implementation of computerized medication carts equipped with barcode scanners and lockable drawers. With our carts and refined workflow, nurses were able to administer medications promptly during each shift with fewer delays or interruptions. The results have been more efficient medication administration, safer patients and higher quality care.
Safety emphasis prompts eMAR implementation
Mayo Regional is one of the more than 1,330 certified critical-access hospitals (CAHs) in the United States, and was named one of the top 100 CAHs in the country by iVantage. Like many other CAHs, Mayo Regional faces the same financial, IT and personnel resource limitations. Safe and high-quality patient care, however, has always been the top priority among Mayo Regional’s 26 physicians, six family nurse practitioners, five physician assistants and 498 hospital/clinic employees.
With new federal government financial penalties imposed on preventable adverse drug events, Mayo Regional needed to update its medication administration process to inhibit these potentially costly errors. After the implementation of eMAR bedside barcode medication verification and improved workflow process, error rates did improve. But a significant percentage of medications were delivered more than one hour after the ordered time, making “wrong time” the most common medication error. In 2011, as a result, the Institute for Safe Medicine Practices (ISMP) and the Centers for Medicare and Medicaid Services (CMS) recommended changing the 30-minute rule for medication administration and removing the time constraints on nurses, thus decreasing the feeling of pressure to take shortcuts to comply with the rule.
While studying workflow, Mayo Regional’s clinical IT nurse discovered that their current system limited medication collection to one patient at a time, causing nurses to line up at the dispensing cabinet. When a physician would order a new drug, the nurse would be required to walk back to the cabinet, often being interrupted by other clinicians or visitors, causing more delays. This prompted some nurses to take shortcuts, such as retrieving drugs for more than one patient and even bypassing the barcode scanning verification step.
Moreover, nurses were not able to securely store the medications on their carts, increasing the risk for error or loss. This information was discussed with the chief nursing officer, and she authorized redesigning the workflow process with the implementation of secure medication carts.
| The Rubbermaid Healthcare M38 RX Mobile Medication Cart features a variety of swappable, lockable drawer sizes protected with a security PIN code system. |
Secure carts solve workflow issues
Research has shown that when nurses are more satisfied with the medication administration process, they are less likely to deviate from the protocol. The results of a survey from two acute care hospitals in the Midwestern United States over six months showed that “exhausted” nurses were less likely to engage in workarounds when they were satisfied with the process.
At Mayo, the first attempt to solve these challenges involved assigning a single nurse for all medication administration over a two-hour span in the morning. This solution was tested on the hospital’s 18-bed surgical unit over the course of one day. It only took a few hours to realize unforeseen patient care and logistical obstacles made it impossible for one nurse to complete the administration in the limited timeframe.
After researching cart implementations at other hospitals, Mayo Regional’s nursing leadership determined that computer-equipped carts with barcode scanners would eliminate the workflow issues, and lockable medication drawers would solve the safety and security limitations of their older carts.
In spring 2010, Mayo Regional purchased three Rubbermaid Healthcare computer-equipped medication carts for its surgical unit and one for the obstetrics department. A main reason the carts were chosen was the variety of swappable, lockable drawer sizes protected with a security PIN code system. These features have since allowed Mayo Regional’s nurses to serve up to six patients for up to four hours without returning to the remote medication station. The carts are equipped with six patient drawers and two larger drawers for medication administration supply storage.
Each cart houses a computer that gives nurses access to Mosby’s drug reference database, so they can search for medications or calculations while still logged in to the eMAR and the barcode verification system. Also included on the carts is a tethered barcode scanner. This allows nurses to utilize a handheld scanner for checking medications and patient wristbands, offering another safety check at the point of care. After each shift, nurses verify that no medications remain in the cart drawers prior to handoff to the next nurse.
Cost and time savings
Since implementation, the medication administration delays have decreased by approximately 40 percent due to the ability to collect and safely store all medications for each nurse’s route. Wasted medication costs, such as dropped pills, have decreased from approximately $300 a month to $30 a month. From an efficiency standpoint, having the eMAR on the cart alerts nurses to changes in medication orders at the point of care, helping avoid errors and extra trips to the dispensing cabinet.
Mayo Regional’s eMAR system helped continue the hospital’s tradition of high-quality patient care, but caused new workflow dilemmas solved through strategic selection and implementation of computerized medication carts. While the cost and time savings are appreciated by the clinicians, the most meaningful benefit is that the technology is keeping patients safe and aiding in their recovery.
About the author
Deb Stroud, R.N., Clinical Specialist in the IT department at Mayo Regional Hospital in Dover-Foxcroft, Maine.
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