BY: KELLY TURNER, PharmD; BARBARA MEYER; and MICHELLE STEWART, BSN
Dr. Turner is senior consultant/manager, pharmacy services, and Ms. Meyer
is executive director, corporate communications, Sisters of Mercy Health System,
St. Louis. Ms. Stewart is vice president, patient services, St. Joseph's
Mercy Health Center, Hot Springs, AR.
A multidisciplinary effort under way across the Sisters of Mercy Health System
(Mercy) promises to do more for patient safety than any other in the system's
history. Called "Mercy Meds," this comprehensive transformation of
the medication use process incorporates technology, strategic partnerships,
supply chain management, and improved work processes to enhance safety and efficiency
in the delivery of medications to patients. The initiative seeks to ensure what
Mercy calls the "five rights" of medication safety: namely, the right
dose of the right drug through the right route at the right time to the right
patient.
Mercy, which is based in St. Louis and has hospitals in four states, began
implementing Mercy Meds late in 2003. The system expects to complete the initiative's
introduction at 10 of its facilities by the end of 2004.
According to the 1999 Institute of Medicine report, To Err Is Human,
7,000 deaths occur annually in U.S. hospitals as a result of preventable medication
errors.1 Adverse medication events occur for
a variety of reasons. One cause is failure to distinguish between look-alike
packages and sound-alike names — for example, Celebrex, an anti-inflammatory
agent, and Cerebyx, a seizure disorder medication. The growing number of new
medications introduced on the market every year also challenges clinicians'
ability to keep current with drug information. Insufficient drug information
has been identified as the most common system failure attributed to medication
events.
Research shows that between 80 and 200 steps may be associated with the administration
in a hospital of a single dose of medication — beginning with the moment
a physician prescribes the medication to the moment it is dispensed by the pharmacy
and given to the patient.2 The largest number
of errors occur in prescribing and administering — the first and last steps.
Most errors are caught at the prescribing stage; only 2 percent are caught at
the administration stage. Because Mercy was no more immune to these errors than
other health care organizations, its leaders recognized that new strategies
were critical to improving medication safety.
"Mercy Meds" was developed in the fall of 2001 when Mercy's pharmacy directors
and other key stakeholders got together to discuss improvements in the structure
of pharmacy services in the system's hospitals. At that initial meeting, five
key strategies were defined. Mercy would:
- Acquire advanced information systems and automation technology, which would
reduce the possibility of human error in prescribing and administering medications
- Manage knowledge through the sharing of information, ideas, protocols, and
"best practices" among the system's pharmacies
- Retain and recruit pharmacists by increasing their level of job satisfaction
and providing continuing education and training opportunities
- Develop a collaborative-care model of practice by shifting pharmacists'
responsibilities from primarily dispensing medications to becoming an integral
part of the patient care team
- Improve contract and formulary management through shared contract and cost
information
By March 2002, Mercy's Leadership Council had endorsed the pharmacy vision.
A business plan was approved by December 2002, and work was begun in developing
the individual elements needed to restructure pharmacy services across the system.
As the process evolved, it became apparent that the initiative was more than
a transformation of pharmacy services — it was also an opportunity to transform
the entire medication use process. The redesign became a collaborative effort
involving hundreds of Mercy clinicians and other staff members, including pharmacists,
nurses, physicians, information technologists, process improvement experts,
and supply chain specialists. Multidisciplinary teams were formed to focus on
five specific aspects of the medication process: pharmaceutical distribution,
bar-coding/repackaging, automated cabinetry, bar-code point-of-care technology,
and clinical pharmacy and knowledge management strategies (these terms are explained
below).
In 2003, the teams worked diligently to design and establish new processes,
acquire and implement the necessary technology, and provide staff training and
education to comprehensively address the issue of medication safety. When Mercy
Meds was introduced at the first Mercy hospital that fall, virtually every aspect
of the medication use process — from streamlining how medications are acquired
to improving the documentation process — had been transformed.
Step-by-Step Redesign
The newly designed process begins at Mercy's Consolidated Services Center
(CSC) in Springfield, MO, which serves as a centralized warehouse and distribution
center for the entire system. As part of the initiative, Mercy has taken the
unique step of becoming its own pharmaceutical distributor. Through a partnership
with the nation's largest pharmaceutical wholesaler, AmerisourceBergen,
the CSC purchases, stores, repackages, bar-codes, and distributes pharmaceuticals
used throughout the system. To take on these tasks, Mercy completed arduous
licensing and qualification procedures by federal and state agencies, including
the Drug Enforcement Administration and various state boards.
Security and quality are key components of the CSC's pharmacy operation.
About $5 million in drug inventory is protected by an advanced security system,
including cameras, motion detectors, electric beams, and a vault for controlled
substances. Quality measures include rigorous procedures to ensure the integrity
and accuracy of the drug repackaging and distribution processes. With all of
these quality controls in place, repackaged medications still must pass a final
inspection by a licensed pharmacist prior to distribution to a Mercy facility.
The CSC receives pharmaceutical orders through Mercy's electronic ordering
system and distributes medications daily to Mercy hospitals via a fleet of secure
vehicles and temperature-controlled storage units. At the hospital, the next
step in the Mercy Meds process begins. The hospital's pharmacists store
many of the pharmaceuticals in computerized drug cabinets on the various nursing
units. These cabinets securely store up to 300 different unit-dose, bar-coded
medications. The availability of drugs on the nursing floor allows nurses to
obtain them in a timely manner once the physician's order has been verified
by a pharmacist. This reduces the work performed by pharmacists, who used to
dispense medication orders from a central pharmacy. In addition, the cabinets
automate the management of drug inventory and can electronically reorder bar-coded
drugs directly from the CSC.
The safety aspects of Mercy Meds hinge on pharmaceuticals being distributed
in unit-dose, bar-coded packaging. Bar-coding enables the point-of-care medication
verification process that nurses use to administer medications to patients.
From a computer that can be moved from patient room to room, the nurse uses
a handheld scanner to scan his or her own ID badge, then the patient's
ID wrist band, and, finally, the medication packaging, thereby verifying accuracy.
All of the "five rights" of medication administration must be in place
for the bar-coding technology to accept the order: the dose, drug, route of
administration, time and patient. If any "right" is not verified,
the system issues an alert. In addition to verifying medication accuracy, the
computer automatically updates the patient medication administration record
in real time. Links to online drug reference resources also are readily available
via the computerized technology.
Education has been an important aspect of introducing Mercy Meds in the system.
At each facility, nursing "super users" have been selected. Trained
in the technology, these "super users" serve as experts during the
introduction of the new processes and technology on nursing units. In addition,
each facility has appointed or hired a "clinical pharmacy coordinator"
to guide pharmacy-related training and education. As the initiative's introduction
has progressed, lessons learned at each facility are shared with those that
have not yet begun implementation. The emphasis on education and collaboration
has further strengthened the medication transformation experience.
Enhancing Pharmacists' Role
Pharmacists are, of course, the best resource for understanding today's
complex medications. By centralizing medication packaging at the CSC and automating
many of the distributive aspects, Mercy has freed its pharmacists to be a clinical
resource for nurses, physicians, and patients. In doing so, the system is responding
to the wish often expressed by patients, family members, and nurses to speak
directly to pharmacists. Mercy knows that such contact helps to ensure the appropriate
use of medications.
This transformation of the pharmacists' role is being led by the system's
team of "clinical coordinators," each of whom is a doctor of pharmacy.
The clinical coordinators began their work by standardizing many policies and
designing and implementing educational modules aimed at strengthening the role
of pharmacists as part of the patient care team. As a result of these efforts,
many pharmacists have been deployed to nursing units to provide medication expertise
at the point of care. The clinical coordinators are now developing pharmacy
education modules designed to provide pharmacists with additional skills sets.
In recognition of Mercy's new role in providing continuing pharmacy education,
it became accredited by the Accreditation Council for Pharmacy Education in
January 2004.
Enhancing the pharmacist's role also aids pharmacist recruitment and retention
in the face of strong competition from other health care organizations and from
retail operations. Mercy Meds aims to improve pharmacists' job satisfaction
through greater patient care interaction, increased collaboration with other
health care professionals, continuing education, and an improved workplace environment.
Mercy's pharmacies, formerly viewed as merely locations where medications
were stored and dispensed, are now becoming an integral clinical service recognized
for providing information and expertise.
A True Team Effort
Mercy Meds has been a multidisciplinary effort involving knowledge experts from
across the system. Although focused primarily on pharmacists and nurses, the
initiative has involved many other staff members. These include:
- Process improvement specialists, who worked diligently to conduct current
state assessments in hospitals and develop gap analyses relevant to future
state design
- Supply chain specialists, who enhanced Mercy's existing distribution
operation to enable the addition of pharmaceuticals and implemented a centralized
repackaging and bar-coding operation
- Legal services staff members, who assisted with the licensing of operations
at the state and federal levels
- Human resources workers, who developed pharmacy-related retention and recruitment
strategies and implemented processes to enable the bar-coding of staff members'
badges
- Engineers and maintenance workers, who completed a variety of construction-related
projects
- Pharmacists, who participated in the implementation of distribution process
changes, including the deployment of automated dispensing cabinets and the
development of bar-coding processes; they also worked collaboratively to enrich
pharmacy education and enhance access to drug information
- Nurses, who worked jointly with pharmacy team members to design processes
for medication distribution, administration, and monitoring; they also helped
select hardware, computer carts and stands, and other devices needed to support
the effort
- Information technology experts, who played a key role in identifying hardware
and software requirements, designing and integrating systems, and installing
wireless networks
- Physicians, who participated in protocol development, contracting, and making
formulary management decisions
- Executive leaders across Mercy, who made the initiative a high priority,
thereby making possible the dismantling of potential barriers and the achievement
of ambitious timelines
The Initiative "Goes Live"
In early December 2003, Mercy Meds was introduced on the neurology and pediatric
floors of St. John's Mercy Medical Center, St. Louis. "Going live"
in this way allowed the system to use the new technology and processes in a
patient care setting and revealed a need for further modifications and improvements.
But it also clearly demonstrated Mercy Meds's ability to detect potential
medication errors and improve patient safety.
As of October 2004, Mercy Meds was in service to approximately 900 patient
beds at seven system facilities. To date, detailed data has been reviewed on
more than 90,000 administrations, indicating that Mercy Meds point-of-care technology
has prevented 386 potential errors. Because point-of-care technology alerts
staff to a potential medication error before the medication can be administered,
it is helping the system shift from reactive post-event medication reporting
to proactive "near-miss" reporting. Near-miss data can be analyzed
even further so as to reduce the possibility of future medication events.
Clinical pharmacy services also are beginning to positively affect the medication
use process. As of August 2004, more than 50,000 pharmacist encounters had been
documented; each of these encounters contributes to improved patient education
and safety, cost-effective care, and positive clinical outcomes.
The entire Mercy Meds experience has strengthened the sense of "systemness"
at Mercy, through inÂcreased interaction among facilities and professional
disciplines, especially nursing and pharmacy. Through process redesign and implementation,
staff members have gained a greater appreciation and understanding of the value
of collaboration and coordination and of the benefits that can be achieved from
them.
NOTES
- Institute of Medicine, To Err Is Human: Building a Safer Health Care
System, National Academies Press, Washington, DC, 2000, p. 2.
- "Pharmacy-Nursing Shared Vision for Safe Medication Use in Hospitals:
Executive Session Summary," American Journal of Health System Pharmacy,
May 15, 2003, p. 1,046.
Copyright © 2004 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.