Grace Cottage Hospital’s 2009 Hospital Report Card

2008 QUALITY IMPROVEMENT INITIATIVES

Patient Safety Project
Project Name: Medication Process Improvement
Time Frame: 2008 and ongoing

Project Description/Problem:
Using the recommendations of a 2007 hospital-wide Continuous Quality Improvement (CQI) team, a new medication administration process was introduced at Grace Cottage Hospital in 2008. Medication administration in a hospital setting is a complex process, and the medical staff and nursing staff expressed frustration with using the computer software in a busy work environment.

Goal:
The goal was to ensure patient safety by implementing a revised medication process, and provide ongoing analysis to improve the flow of information between the employees on all shifts involved in the process.

Intervention Process:
1. A computerized medication dispensing system, Pyxis, was introduced.

2. A specialized technology position was added to the hospital’s staff.

3. A task force consisting of staff members from the nursing, pharmacy and information technology departments was formed to share ideas and discuss medication administration improvements.

4. Grace Cottage contracted with a “night pharmacy” organization so that a pharmacist is able to electronically review medication orders when the hospital in-house pharmacy is closed.

Evaluation Process and Results:
1. The computerized Pyxis medication dispensing unit interfaces with the hospital’s computer to make sure that the right patient is given the right medication by the right procedure at the right time. Initially, the bar code system needed to be adjusted to fit the needs of Grace Cottage, and the staff was trained in its use. Pyxis has proven to be a great success and an additional check in the medication process.

2. The specialized technology position has provided staff with support to critique individual problems with the computer software. This has increased satisfaction and skill with the system. The introduction of shortcuts on the computer screen has improved timely accessibility for the medical staff. There has been improved communication and collaboration between all the hospital departments involved.

3. Contracting with a night pharmacy has improved the medication process for patients and staff during the night shift. A pharmacist is promptly available twenty-four hours a day to review all medication orders, verify allergies, check for potential drug interactions, and conduct other pharmacy reviews prior to administering the patient’s first dose.