Trouble with the Pharmacy—Case for Chapter 7

Trouble with the Pharmacy—Case for Chapter 7 Patricia A. Patrician, Grant T. Savage, and Eric S. Williams Part One “Darn! I have to call Pharmacy again,” Lisa, staff nurse on 6 East, muttered under her breath. “This is the third time today and it’s not even noon!” She left the Omni-Cell Cart in the medication room and proceeded to the phone at the nurses’ station. She dialed the familiar number—she had it memorized of course—and thought, “There has to be a better way.” For the past few days, she had noticed an increase in the number of medications missing from the medication carts. Two days in a row, she was able to get a vitamin from another patient’s medication drawer and administer it to her patient, but she knew this did not solve the problem. She was just trying to make it through her shift and get the patients what they needed. In the meantime, on 6 West across the hall, Deirdre had a similar issue. The morning dose of her patient’s oral antibiotic was not in the drawer, so she gave the dose that was labeled “evening dose.” The evening shift nurse then had no evening antibiotic dose in the drawer and had to call the pharmacy to get a replacement. Numerous calls were being placed to the pharmacy. The pharmacy technicians were so busy fielding phone calls that none of them were available to deliver medications, so the staff nurses had to leave their units and patients and go to the pharmacy in the basement to retrieve their missing doses. The pharmacy technicians began complaining to their supervisors that those 6th floor nurses call so frequently that they do not have time to do their work. Nurses complained to each other that pharmacy was not stocking the medication carts correctly. DISCUSSION 1. In an organization that espouses a good patient safety culture, what should happen next? Part Two Lisa notified her nurse manager, Katie, that there was an increase in the number of medication doses that were unavailable at the time of their scheduled administration. Likewise, Marcus, the nurse manager on 6 West, heard from his night shift nurses that they had to “run to pharmacy” many times during the night to get medications that were not in the medication cart. That same morning, Katie was on the way to a Nurse Manager Meeting when she ran into her colleague on 6 West, Marcus. After exchanging greetings, Katie asked Marcus how it was going. Marcus explained that several of his nurses complained about pharmacy not stocking the medication carts appropriately, but he had no time yet to verify this or to talk to the pharmacist. It was on his “to do” list though. Katie explained that one of her staff nurses made this same complaint earlier that day. They both decided to raise this as an issue to be discussed at the Nurse Manager Meeting. “Is anyone else having trouble with Pharmacy?” Marcus asked at the end of the meeting. “My staff nurses are complaining that the med carts are not stocked correctly.” Many hands went up, and others chimed in that they thought it was an issue only for their specific units, but now they realized how widespread this problem was. Because the Nurse Managers practice shared governance, they appointed Katie and Marcus to lead a Performance Improvement (PI) Team to figure out what the problem was and to take action. Three other Nurse Managers volunteered and joined the team; after a short meeting, the team agreed upon a plan. DISCUSSION 1. At this point, what should the PI Team’s plan entail? Part Three The PI Team members queried their respective staffs to better understand the problem. The staff nurses’ main complaint was that the 10:00 a.m. medications for patients were not in the medication carts. The pharmacy techs’ main complaints were the massive number of phone calls and that the carts were being returned with unused medications that were being thrown away. The nurse managers and pharmacy representatives on the team met together to develop a process flow diagram of the medication order and administration process. Figure 18-7 depicts their process flow diagram. The PI Team also agreed to maintain a 24-hour record of missed doses and calls to pharmacy during the next work day. The team met again in two days and determined the numbers of missed doses and calls to pharmacy over a 24-hour period in the five units that were participating in the PI Team. Figure 18-8 contains this information depicted in a run chart format with time on the horizontal axis (hours of the day) and missed medication dosages on the vertical axis. FIGURE 18-7 Process Flow Diagram of Medication Administration Process FIGURE 18-8 Run Chart of the Number of Missed Doses and Calls to Pharmacy DISCUSSION QUESTIONS 1. Please compare Figure 18-7, the process flow diagram of the medication process, and Figure 18-8, the run chart of missed doses and calls to pharmacy. What is missing in the flow diagram (Figure 18-7) that is evident in the run chart (Figure 18-8)? Explain your answer. 2. Given the data that has been collected and analyzed (see Figures 18-7 and 18-8), what is still missing from the quality improvement analysis? Part Four After examining the flow chart and the run chart, the PI Team discussed why medications were missing during administration around 10:00 a.m. The pharmacy representatives shared that the pharmacy had changed their policy on cart restocking based upon what the new Pharmacy Director was accustomed to in his last job—carts changed out at 9:00 a.m. What the Pharmacy Director did not understand (and did not bother to ask) was that medication times for routine (once) daily medications were set by the hospital for 10:00 a.m. Based on the hospital’s once-daily schedule, the nursing staff scheduled twice-daily medications for 10:00 a.m. and 10:00 p.m. As a result of the change by the Pharmacy Director, medications that were supposed to be given at 10:00 a.m. were being returned to pharmacy as unused. DISCUSSION 1. What solution should the nurse managers and the pharmacy director implement? Part Five A simple change in the cart turnover time to 11:00 a.m. quickly rectified the problem, thus increasing the doses available for morning and twice-daily medications, decreasing the phone calls to pharmacy, decreasing wasted medications, and eliminating the workarounds that were potentially hazardous to patient safety. DISCUSSION 1. Given the solution, is there a need for any additional quality improvement in the medication administration process? SCIENCE HEALTH SCIENCE NURSING HSM 301

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