Slide Presentation from the AHRQ 2008 Annual Conference
On September 10, 2008, Amy Vogelsmeier, Ph.D., R.N., made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (835 KB).
Slide 1
Nursing Home Medication Safety: Bringing New Tools to Old Challenges
Amy Vogelsmeier PhD RN
Jill Scott-Cawiezell, Principal Investigator, PhD RN FAAN
AHRQ 5 UC1 HS014281-02HRQ
University of Missouri (MU) Sinclair School of Nursing
Slide 2
Primary Study Aim
Evaluated the impact of technology and focused quality improvement efforts upon medication safety practices.
Slide 3
Study Overview
- Five nursing homes in three states participated in the study:
- Ranging in size from 60 to 400 beds.
- Both urban and rural.
- Both profit and not-for-profit.
- The nursing homes implemented full Electronic Health Records (EHR) and then Electronic Medication Administration Records (eMAR).
- The team observed medication administration and related processes for approximately 16,000 medications.
- Nursing homes each had a focused quality improvement team that met monthly throughout for about two years.
Slide 4
Slide shows photo of a staff member of a nursing home using a computer with Electronic Health Records (EHR) and Electronic Medication Administration Records (eMAR).
Slide 5
How Has Technology Helped the Medication Administration Process?
- Documentation of assessment parameters correlated to specific medications helped link clinical data to medication administration.
- Elimination of monthly MAR changeover reduced risk of medication errors and saved valuable staff time.
Slide 6
How Has Technology Helped the Medication Administration Process? (continued)
- "Flags" on eMAR are helpful—the addition of green flags for new orders and yellow highlight for PRN ["as needed"] monitoring have seen a positive response from staff.
- Reduced transcription from five points to two points—with the potential to go to remote physician access.
Slide 7
Pre eMAR Order Entry
Slide shows a decision tree with this sequence:
- New medication order received.
- Transcribe order to physician order sheet.
- Compare new order to existing orders
- Does order require clarification?
- If Yes:
- Nursing home (NH) contacts physician to clarify order.
- Order clarification received.
- Transcribe revised order to physician order sheet.
- Transcribe order to physician order sheet MAR section.
- If No:
- Transcribe order to physician order sheet MAR section.
- Telephone order?
- If Yes:
- Transcribe order to telephone order sheet, route copy to physician, place copy in chart.
- Transcribe order onto MAR.
- If No:
- Transcribe order onto MAR.
- Fax order to pharmacy.
Slide 8
Post eMAR Order Entry
Slide shows a decision tree with this sequence:
- New medication order received.
- Transcribe new order into eMAR.
- Compare new order to previous orders.
- Does order require clarification?
- If Yes:
- NH contacts physician to clarify order.
- Enter any new order into eMAR.
- Discontinue previous order.
- Post order from eMAR; copy to chart and to physician.
- If No:
- Post order from eMAR; copy to chart and to physician.
- Telephone order?
- If Yes:
- Transcribe (handwrite) new order to physician order sheet.
- Verify eMAR printed order matches handwritten order on physician order sheet.
- If No:
- Verify eMAR printed order matches handwritten order on physician order sheet.
- Fax eMAR printed medication order to pharmacy.
Slide 9
Using Data to Improve Processes
- New order reports identify new orders from the past 24 hours:
- Useful to stay current on resident condition and verify accuracy of new orders.
- High risk medication reports, such as anticoagulant and psychotropic agents, identify specific residents that may require careful monitoring and identify facility-wide trends of medication use.
Slide 10
Using Data to Improve Processes (continued)
- Late medications tracked via time stamping of actual medication administration times:
- Useful to identify trends of high volume medication passes and systems issues that impede medication administration.
- 30 day look back provides a 30 day MAR for each resident.
- Medication exception report tracks documentation as to why medications were not administered:
- Useful to identify systems impeding medication administration.
Slide 11
Moving from Paper to Touch Screen
- Quicker process.
- Legible MAR.
- Focused eMAR for current medication administration.
- More organized medication administration.
- More accessible MAR.
- More accessible related health information.
- Real time medication orders.
Slide 12
Technology Uptake Can Lead to Improvement
- Maximizing success with technology requires diligence and creating interfaces which lead to updated clinical processes.
- Data, data, data can drive how to maximize technology to improve resident safety and guide more directed and focused process improvement strategies.
- Workarounds are a reality and occur despite good process improvement or instead of good process improvement.
Slide 13
What is a Workaround?
- An informal temporary practice for handling exceptions to normal workflow.
- A workaround occurs as a worker perceives some disruption or block in the system that prevents the worker from completing a task as desired.
Slide 14
Workarounds when the process had been improved and integrated into technological updates
| Clinical Process |
Block |
Workaround |
| Medication dose limits in eMAR dictionary |
Unsafe dose not available in dictionary |
Selecting dose not matching ordered dose |
| Administering medications using eMAR |
Time, perceived workload |
Administering medications via the dispensing device without checking eMAR |
Slide 15
Workarounds when the process had not been improved and integrated into the technological updates.
| Clinical Process |
Block |
Workaround |
| Accessing EHR for clinical information |
Slow wireless system |
Relied on handwritten notes and verbal information exchange |
| Communicating new orders to pharmacy |
One fax machine for 180 residents available 24 hours a day |
Handwriting and calling new orders to pharmacy |
Slide 16
How Facilities Defined Success
- Data from the eMAR systems results in good quality improvement (QI) information.
- Increased communication, increased focus on the work, and a heightened awareness of the potential for mistakes... "we cannot let our guard down, we always need to think about the potential for error."
- Recognizing that systems are underlying most errors; feel like "we are becoming better problem solvers."
Slide 17
What Have Been the Biggest Challenges?
- Working with state surveyors.
- Learning to maximize the use of data for real information.
- Underestimating the learning curve.
- Managing implementation with limited onsite resources.
- Recognizing that technology will not solve all the problems.
Current as of February 2009
Internet Citation:
Nursing Home Medication Safety: Bringing New Tools to Old Challenges. Slide Presentation from the AHRQ 2008 Annual Conference (Text Version). February 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/annualmtg08/091008slides/Vogelsmeier.htm
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