North Country Hospital Quality Improvement Initiative 2008

Full Service
Community Hospital
(802) 334-7331

Toll Free
(800) 750-7331

24-Hour Physician Staffed Emergency Room
(802) 334-7900

TTY
(For Hearing-Impaired)
(802) 334-7900

Click the icons below for Diabetes Information

Hospital Report Card 2008

Quality Improvements

Safety Improvement Project

Name:	Failure Mode and Effects Analysis
Time Frame:	Data gathered September 2007 through December 2007
Description:	The nursing and quality office wanted to fully understand and investigate potential weaknesses in our medication administration process from physician order all the way to administration of medication to patient. This project was selected to be proactive in preventing medication errors and it was also selected in response to nursing feedback regarding a goal to improve the information recorded on the pharmacy medication administration record.
Project Goals:	The goal was to map the medication administration process on the Medical Surgical, ICU, and Maternal Child units. After creating the process maps, we made some changes to the sub-processes and standardized our best practices throughout the three units. The process map is included.
Measures:	We gathered data on our internal reporting of medication errors. The numbers are too small to draw statistically valid conclusions at this point. However the results are still presented showing measures in progress. In the six months preceding the interventions (changes in sub-processes) the number of monthly reported medication errors was a high of seven and a low of two with the median rate based on doses as the denominator of less than .5 (numerator/denominator1000). In the four months following the interventions (changes in sub-processes) the number of monthly reported medication errors was a high of six and a low of one with the median rate based on doses as the denominator of less than .5 (numerator/denominator1000). Going forward, it will be difficult to assign results to interventions vs. reporting behavior.
Countermeasures To Potential Process Failures:	1. Meds can be inadvertently moved within the PYXIS system. Nurses need to be very careful particularly when closing drawer. 2. Process requires consistent dual check by second nurse on meds administered. 3. Implement and standardize guidelines across units for administration of high risk drugs. 4. Change process to insure Medication Administration Record is updated after medication is administered and not before. 5. Redesign process to create improved accountability regarding disposition of medications that are to be destroyed.
Contact:	Stephen Halikas, Director of Quality & Risk Management 189 Prouty Drive, Newport, VT 05855 Tel: 802.334.3248 Fax: 802.334.4172 email: shalikas@nchsi.org
	Medication Distribution Process