Medication administration errors associated with transitions of care in inpatients receiving dialysis in the setting of partial implementation of an electronic medical record
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1. The document describes medication administration errors that occurred during transitions of care for a patient receiving dialysis who was transferred between units. 2. The team created process flow maps to identify gaps, such as a lack of protocol for nursing handovers and different documentation systems between units. 3. Interventions included stocking basal insulin in the dialysis unit and developing strategies like those on the nephrology ward to improve safety during patient transfers.
Medication administration errors associated with transitions of care in inpatients receiving dialysis in the setting of partial implementation of an electronic medical record
- 1. Medication Administration Errors Associated with Transitions of Care in Inpatients Receiving Dialysis in the Setting of Partial Implementation of an Electronic Medical Record and Computerized Physician Order Entry Erik Venos, IrfanDhalla, Catherine Yu Department of Medicine, St. Michael’s Hospital, Toronto, ON
- 2. CONTEXT Her usual insulin regimen, a morning meal STAKEHOLDER IDENTIFICATION AND insulin injection and a basal insulin ENGAGEMENT Patient transfers between and within injection, was reinitiated facilities are associated with negative She was transferred to the dialysis unit at Nephrology GIM patient outcomes, with the administration 0730 for her regular dialysis GIM staff of insulin being a problematic area Her blood sugar was normal at 0800, 17.8 Dialysis MD GIM resident This project aimed to identify issues with mMat 1200 and 27 mM at 1500, requiring Dialysis fellow Endocrinology staff transitions within the hospital on these 10 units of supplemental insulin for Renal pharmacist GIM pharmacist outcomes Dialysis RNs correction GIM RNs The eMAR did not report that the morning SETTING meal insulin or basal insulin was Face-to-face and by email administered General internal medicine (GIM) ward and a CREATION OF PROCESS FLOW MAPS nephrology ward of a tertiary care centre, INTERVENTION which operated a dialysis unit, serving out- 1. Physician ordering to nurse and inpatients Identifying processes that led to this error administration for patients admitted to the GIM ward (figure 2) Used computerized physician order entry (CPOE) along with an electronic medication 2. Patients admitted to GIM ward requiring Four steps were undertaken: dialysis, focusing on how insulin was administration record (eMAR), both being given on dialysis days (figure 3) recently implemented on inpatient units in 3. Patients admitted to nephrology ward the hospital Identification of the relevant stakeholders requiring dialysis, focusing on how insulinwas given on dialysis days (figure PROBLEM/ISSUE 4) Engagement of the relevant stakeholders Focusedon the medication administrations MEASUREMENT AND ANALYSIS Description and analysis patient transfers and transitions of care between a GIM using a process flow map ward and a dialysis unit for a patient with Identified a more complex system for Map 1 type 1 diabetes and end stage renal compared to Map 2 (Figures 2 and 3) disease admitted to hospital Utilizing this engagement and description Found issues with insulin administration to attempt to improve the process What medications are given before Where does the patient eat? the patient leaves the unit? Does the dialysis RN give insulin routinely? What medications are deferred? Will administered medications be charted Inpatient Patient in dialysis Inpatient returns What handover between RNs on theeMAR or apaper chart? leaving ward for unit for 4 hours to home ward occurs? dialysis Figure 1: Considerations for designing a process flow map for hospitalized patients when leaving from and returning to their home unit from dialysis
- 3. Patient, receiving Medications are entered into Pharmacist acknowledges Medications are sent to floor dialysis, is admitted to CPOE by physician order and approves where RN receives them hospital medication RN (via barcode) confirms that Patient receives medication from RN as RN acknowledges patient receipt of the patient’s medications ordered (insulin is drawn up in syringe medication in electronic record belong to patient from floor supply vial) Figure 2: A process-flow map of medication administration for patients on a GIM ward Patient, receiving Medications are entered into Pharmacist acknowledges Medications are sent to floor dialysis, is admitted to CPOE by physician order and approves where RN receives them hospital medication Floor RN gives patient Sliding scale insulin medications pre-dialysis and Dialysis RN notes insulin administered or charts this oneMAR correction factor. Does physician called about not give standard concern (medication insulin (assumes given Floor RN notes administration noted on Floor RN holds medication on home unit?) scheduled during dialysis to be medications given in paper MAR) dialysis unit given after dialysis Floor RN gives scheduled Performs capillary Insulin medications post-dialysis blood glucose and Floor RN should print medi- Pt transported to GIM assesses whether cation list and eMAR prior to RN to enter medications ward from dialysis patient will eating. patient leaving ward into eMARgiven in Meal is eaten in dialysis dialysis and after dialysis Dialysis RN should No specific protocol review patient’s Patient goes off ward for existed as how insulin Dialysis RN looks at medications from dialysis was noted patient medication list paper list Medication given or and dialysis medication physician called about list to determine IV concern meds and antibiotics to give during dialysis Other medications Figure 3: A process flow map of medication administration for patients on a GIM ward receiving dialysis, on a dialysis
- 4. Insulin Dialysis RN performs Floor RN notes medica- Dialysis RN administers capillary blood glucose tions given in dialysis unit mealtime and basal insulins and assess whether Patient leaves ward for provided by floor RN Floor RN gives scheduled eating dialysis. Scheduled insulin is medications post-dialysis Patient returns to drawn up from floor stock RN to enter medications Dialysis RN looks at nephrology ward by floor RN and goes with into eMARgiven in the patient to dialysis unit patient medication list Dialysis RN gives mealtime dialysis and after dialysis and dialysismedication medications provided by list to determine IV floor RN Insulin charted as meds and antibiotics to received in dialysis unit Other medications give during dialysis Figure 4: A process flow map for patients admitted to a nephrology ward receiving dialysis, on a dialysis day Maps were distributed among the relevant 5. Basal insulins were not routinely stocked 3. The admission of patients with non- stakeholders for feedback and information in the dialysis unit dialysis related chief complaints to the provision nephrology ward The practices on the nephrology ward (on 4. Flagging the charts or medical record of GAPS IN CARE the same floor as the dialysis unit) all patients with type 1 diabetes revealed an interesting workaround to the system (figure 4) LESSONS LEARNED 1. The dialysis unit is an outpatient facility Floor RNs prepared CPOE-ordered insulin in using paper medication orders and a syringes, administered in dialysis when the paper MAR while the inpatient units use 1. The transition of care of patients patient could be observed to be eating between units, especially the dialysis CPOE and an electronic MAR; outpatients supply and administer their unit, can lead to medication errors, CONTRIBUTION TO PATIENT SAFETY AND particularly regarding insulin own insulin and other medications QUALITY IMPROVEMENT administration 2. Patients were transferred between 2. CPOE and eMAR systems can have unitswith no specific protocol for nursing Basal insulin to be supplied in the dialysis drawbacks that need to be noted during handover unit, so that insulin did not have to come and after implementation 3. The patient was transferred between from the home ward if it was not supplied 3. The engagement of relevant stakeholders units at 0730, a time when nursing by the home ward is an important strategy to gain handover occurs Other measures were proposed for information about systems of care consideration to improve patient safety: 4. The development of process flow maps 4. Patients were off the ward in hemodialysis, not briefly, but for four or 1. Development of the same workaround, are helpful tools to understand complex more hours, making the routine non- as on the nephrology ward, for other processes in the hospital administration of medication until the units 5. Understanding these processes can lead patient returns to the unit problematic 2. Providing dialysis RNs training on CPOE to problem identification and the and eMAR creation of workable solutions