By Susan Curtis, RN, BSN

PORTLAND’S, MAINE MEDICAL CENTER, THE LARGEST HOSPITAL IN MAINE, IS A 606-bed facility, a teaching hospital and an active research center, providing comprehensive services in all medical specialties. Because Maine Medical Center prides itself on utilizing the latest technologies to promote safe patient care, our safety pharmacist and risk director, intrigued by a presentation of the MedAccuracy product AU MEDS at a 2004 MEPI (Medication Error Prevention Initiative) meeting, brought the idea to our organization’s leadership. The members of the MEPI group had agreed that actively examining the medication system, via an observational technique, could provide valuable information to improve safety and prevent medication errors. The Maine Medical Center’s patient safety committee endorsed the recommendation. By increasing our understanding of medication errors, we believed we could support improvement efforts for error prevention. The Center for Performance Improvement developed a job description for a medication safety observation nurse, and this nurse was trained in April 2005.

The AU MEDS observation method consists of a certified medication observer (a nurse, a pharmacist, or both) shadowing nurses during busy medication administration times, typically from 8AM to 11AM. The observer documents everything about each individual medication observed – including where the nurse obtains the drug; the name, strength, and form of the drug; and its preparation details – and actually follows the nurse to the patient’s room, in order to accurately capture medication administration and consumption. The observer makes note of all circumstances that may adversely or positively impact the process, such as interruptions to answer calls, consulting a drug handbook, or obtaining a drink for a patient. The observer also documents the total time taken to administer the medications, from the beginning of the med pass until the patient receives the medications.

The observer has no prior knowledge of what medications are ordered and must avoid looking at any sources of this information, but he or she does make note of what med administration source the nurse uses. Following the data collection, which takes anywhere from two to four hours, the observer compares what was administered to what was actually ordered. When discrepancies are found, the observer looks to additional notes made during the observation, as well as other details, such as order entry, to determine possible clues to causes. If necessary, the observer may consult with the nurse regarding the observation to gain a better understanding of the process or to alert a nurse to an error that might impact the patient’s care. This kind of intervention has occured infrequently, and when it is has, our staff actually appreciated it, as patient safety is our priority.

Once all observed medications are reconciled with the orders and the accuracy is determined, each observed dose is entered in the MedAccuracy database. At our facility, we elected to provide feedback to the nursing staff via a same-day data report. The report lists the number of observations, the number of correct doses, the type of incorrect doses, and any observer comments regarding clues. To maintain anonymity, no nurse or patient identifiers are included. Nurse managers are also provided with the same-day reports, which have increased our nurse managers’ awareness of the frequency of medication errors and have provided opportunities for individual units to implement improvements specific to their patient populations.

It is important for nurses to understand that this program is meant to collect data regarding systems issues and improvement opportunities around medication safety, and is not a method to evaluate individual nurses. Most staff members are supportive of the effort and understand its value for patient safety.

The observation nurse reports data regularly to several leadership groups, including the patient safety committee, the adverse drug event committee, and the pharmacy and therapeutics committee. We use our Balanced Scorecard on a monthly basis to report data and to trend our overall medication accuracy, as well as individual nursing unit accuracy. By examining our medication system on an ongoing basis at the place in the system where it matters most — the bedside — we are able to quantify our medication error rate. More significantly, we are able to qualify errors by looking at the frequency of error types, the clues to the cause of inaccurate administration, and, most importantly, the changes we, as an institution, can make to our system to support medication accuracy.

Through the MedAccuracy program, we are approaching 5,000 observed doses. We have utilized the data collected to partner with pharmacy, nursing, and the adverse drug event committee to implement numerous improvement projects, ranging from tasks as simple as adding an acknowledgment statement in our automated dispensing machines to alert nurses of the potential risk of crushing a long-acting narcotic to a more involved improvement of changing the way new orders for medications are dispensed from our pharmacy. We have seen a significant decrease in our wrong-time and omission errors (see preceding graph) and are continually evaluating our data to look for further improvement opportunities.

Our observation nurse participates in many medication system improvement initiatives, such as our EMAR implementation (going live in March 2007) and our bar coded medication administration project, also slated for 2007. By participating in MedAccuracy’s AU MEDS program, we are able to use the knowledge gained to more successfully plan and implement both small and major changes to our medication-use system, and we are poised to evaluate any and all interventions that may impact safe medication administration.

Susan Curtis, RN, BSN, is the medication safety observation nurse for the Maine Medical Center’s Center for Performance Improvement.