1. The Health Roundtable Improving the Accuracy of Medication Profiling Process Presenter: Prathna Singh, Prem Kumar Hospital Code Name: Counties Manukau District Health Board Innovation Poster Session HRT1215 – Innovation Awards Sydney 11 th and 12 th Oct 2012 1 4-4d_HRT1215-Session_SINGH_CMDHB_NZ

2. The Health Roundtable KEY PROBLEM Background  Availability of the right medication at the right time is vital for patient care; any error can lead to a serious outcome. With the introduction of the Pyxis system, an automated dispensing machine, drugs can be accessed from machines on the wards using patient medication profiles that Pharmacy staff compile electronically using the patients medication chart. Problem  The medication charts received by pharmacy are not always accurately profiled with what is prescribed. This can lead to a Nurse accessing and then administering the incorrect medication it to a patient. 2

3. The Health Roundtable 3

4. AIM OF THIS INNOVATION  The aim of this improvement was to reduce the number of near misses in the profiling process, therefore increasing the accuracy of the patient profile of medications available to nurses on the ward. 4

5. The Health Roundtable BASELINE DATA  An audit of 100 charts over one month found that 10 patient profiles that appeared on the Pyxis machine did not match what was charted for the patient on their medication chart. Collecting this data was time consuming and required a lot of staff resource, hence the team devised the idea of collecting the “number of near misses” in Pharmacy as a proxy measure.  These errors in the first step of the profiling process increased the possibility of errors getting past the final check and therefore the possibility of nurses accessing and administering incorrect drugs to a patient. 5

6. The Health Roundtable KEY CHANGES IMPLEMENTED  Interruptions  Telephone - PABX system was introduced and phone placed in relevant areas to reduce the telephone interruptions while profiling  Sitting Layout- New sitting arrangement identified to accommodate the process flow and reduce interruption from other processors.  Standardised process for profiling  Annotation - Variation in the way each person profiled a medication chart was reduced by standardising the annotations used on medication charts.  Process steps - Checklist created for the process.  Knowledge management  Standardised Training  Staff Credentialing  Dashboard created to initiate improvement discussions 6

7. The Health Roundtable OUTCOMES SO FAR Improvements identified and trialled 7

8. The Health Roundtable LESSONS LEARNT  Improvements that come from the team to make changes more sustainable.  Proxy measures can be used to measure the improvements instead of relying on time consuming one off audits. 8