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Case Study: Three Links Care Society Safe medication practices in the LTC setting

Interview date:

January 2010

Technology in use since:

March 2008

Director of Care:

Rita Steeple, RN

Health care facility:

Three Links Care Society 2934 E 22nd Ave Vancouver, BC V5M 2Y4 Canada http://threelinks.com/

Technology partner:

Catalyst Healthcare www.catalystrms.com

Interviewed by:

Kasumi Oda Director, Strategic Marketing kasumi_oda@catalystrms.com

ÂŠ 2010 Catalyst Healthcare Ltd

Rita – thank you for making time to share your experience; please tell us about your facility. Three Links Care Centre is a publicly funded non-profit Long Term Care facility and an affiliate of the Vancouver Coastal Health Authority. The Centre consists of three floors with 90 private bedrooms on the second and third floors and a 6 bed peritoneal dialysis unit, with nursing stations located on each unit. Interdisciplinary care services are provided on a 24-hour basis by a team of professional staff including Registered Nurses (RNs) / Registered Psychiatric Nurses, Licensed Practical Nurses, Clinical Dietitian, Social Worker and Music Therapist. Medical services are provided by House Physicians, supported by community General Practitioners. Occupational Therapy, Physiotherapy and Speech Language Pathology are available through the Evergreen Health Unit of Vancouver Coastal Health Authority. Resident Care Aides, Rehabilitation Assistant and Recreational Aides complete our well-rounded and dedicated staff. Our goal is to enhance the quality of residents’ lives by focusing on both their physical and emotional needs. You’ve been using oneMAR since March 2008, can you give us some background on it? Catalyst oneMAR is a real-time, internet based system that integrates us with our pharmacy service provider, meaning 100% accountability to the dose level from filling a prescription to administration. With incident reviews identifying the error, individual responsible, specific date / time, and location (facility or pharmacy), we have rapid identification of the source of the error, a level of detail unattainable in the past. Remediation is rapid, there is no more trial and elimination; we have risk management, quality improvement and solution implementation at the right point in the process. Historic, previously untraceable errors are a thing of the past due to accurate and timely documentation integral to oneMAR. When a complex process is made safe and user friendly with basic training done in minutes, the initial buy-in and ongoing support from nursing becomes a given. My team would revolt if I tried to take oneMAR away; our goal is to be paperless by 2011! What are some of the results that you’ve experienced from the adoption of oneMAR? With the adoption of oneMAR, we have benefitted from efficiencies both internally and externally, including real-time connectivity with our off-site community pharmacy provider in the potentially high risk area of medication administration. There’s the added safety of barcode scanning to ensure the right medication is given to the right resident at the right time, the improved communication both internally and externally for all medications administered, and the added efficiencies due to accurate inventory management. We have realized significant improvements in our day-to-day operations which translate to reductions in nursing workload, improved resident care, time savings, a decrease in inventory ordering, fewer medication related errors, and motivated staff. Time savings & quality improvements – less nursing time is spent on the labor side of medication administration. Time previously spent on paper documentation to communicate and assess the mental and physical status of residents has been replaced by time with the residents ensuring that medications are actually taken. oneMAR has improved documentation accuracy by addressing traditional error points such as required responses for PRNs (as needed medication) and “standing orders.” Despite longestablished standards of practice within nursing, the reality is that documentation has often been hit and miss for the “real-time” sign-off indicating administration or the responses required to assess medication effectiveness. oneMAR prompts documentation of responses to “as needed” PRN medication and standing orders ensuring consistent, accurate and readable documentation. Implementation of oneMAR has achieved system efficiencies and reduced risk at historical error points.

Safety in medication administration – adherence to the to “7 Rights” of medication administration: Right medication, Right client, Right dose, Right time, Right route, Right reason and Right documentation are embedded in nursing practice. Still, it is one of the most error prone aspects of healthcare resulting in added costs to the system – if the evidence based on the literature is extrapolated across British Columbia’s 31,500 Long Term Care/Assisted Living beds, there are between 2 and 10 medication errors per 100 beds per month. This equates to a range of 630 to 3,150 medication errors per month. Studies indicate that 44% of these are either fatal, life threatening, or serious. This translates into a range of 277 and 1,386 being either fatal, life threatening or serious medication errors. 52% of these are avoidable which in turn results in between 144 and 721 being preventable each month. Over a year, between 1,730 and 8,649 preventable fatal, life threatening or serious medication errors occur across the 31,500 residential care beds. These translate into hospital admissions and considering that these people will stay in hospital longer and have complex problems, the impact on the hospital sector is between $ 17.3 M and $ 86.5 M annually (AJM, 109, 87 94). In the US, preventable adverse drug events generate $2B in direct hospital costs each year (JAMA 2008). Seniors are among the most susceptible to the results of drug errors and prevention has always been a key focus. The use of the oneMAR supports and enforces the 7 Rights:

Right patient / resident: photos of patients / residents are on the screen with the medications to be administered providing for accurate identification, especially important in meeting standards set by regulatory colleges and Accreditation Canada. oneMAR doesn’t allow for medication administration to the wrong resident as pop-up warnings appear to repeatedly question the dispensing nurse;

Right drug: medication image verification available at the time of medication administration enables nurses to visually identify the drug being dispensed as the right drug. Scanning provides real-time notification for discontinued medications. If a multi-dose package contains three medications, one of which is discontinued, a single scan will notify that two are safe to administer and one is discontinued and should not be administered;

Right reason: the listing of all resident diagnosis and allergies allows the nurse to ensure that there is a documented diagnosis and rationale for administration of the prescribed medication;

Right dose – doses dispensed by pharmacy automation and checked by pharmacists / pharmacy technicians are confirmed with barcode scanning further supported by the visual identification and markings provided by manufactures on the medications themselves;

Right time: scanning brings up all doses for that resident at that time. Once administered, each dose is signed with an electronic signature accompanied by a date and time stamp. This information is immediately accessible to any other healthcare provider viewing the medication administration record. Scanning provides real-time notification for medications flagged as onhold;

Right route: information is legible and easily accessible on the medication administration record;

Right documentation: the electronic record is accessible in real-time to other healthcare providers. oneMAR identifies and records any medication that was not administered in its entirety, with the reason, or any medication which was administered outside of the accepted medication administration window. Users are prompted to record any missed or omitted documentation with system prompts.

Case study: Three Links Care Society

Enhanced communication – immediate ability for healthcare providers to access and print real-time medication administration records (MAR) from any computer terminal for emergency transfers or off-site appointments. Prior to oneMAR, staff removed pages from the MAR book to photocopy, creating a potential error point for the receiving facility in the medication reconciliation process. Missing medication doses or not being able to account for all MAR pages caused delays and confusion in care delivery. Electronic ordering eliminates the need for faxing, and ensures that requests are legible, complete and sent in a timely manner and not forgotten – there’s even a feature which allows nurses to reorder the contents of a dropped / wasted multi-dose package at the time of occurrence. Alerts regarding pending requests reduce duplicate orders and improve efficiency for pharmacy and facility. Each step in the process is documented, time and date stamped for all users to access, enhancing communication. The frustrations of missed communication have been eliminated. Improved resident care – oneMAR allows for review of any resident incident report which may be related to a prescribed medication. With the ability to view the live MAR at any time from anywhere, patterns of behavior in relation to medication are easily identified. For example, it’s easy to see that a nurse has administered medications late, identify whether it’s a recurring issue and if additional training or staffing is needed. It’s also easy to see if residents routinely request PRN medications, and we have the ability to meet with physician / pharmacy to make that PRN a routine medication and keep the resident from being in pain, for example having Tylenol as part of the routine meds given prior to a physiotherapy appointment vs. upon request following the appointment. Physicians are able to access the MAR without having to spend time finding a nurse with the paper record and evaluate effectiveness of any prescribed medication changes. When we do catch a medication error such as a pill in the wrong package, they can be traced back to the source, again supporting additional training or introduction of more stringent checking. Customer satisfaction – residents and their families appreciate how quickly we can provide documentation to support a leave of absence. Traditionally we had to find a resident chart and photocopy information which took a long time…with oneMAR all users have access to up-to-date information for all of our residents. Acute care centers are also our customers, the introduction of oneMAR has made us very popular with them! All residents leaving our facility are accompanied by complete, legible and accurate documentation, including an up-to-date MAR, allergies, diagnosis, etc. Inventory management – we have seen a significant elimination of surplus stock in med rooms with the migration to multi-dose strip packaging and oneMAR. All re-orders and requests are sent electronically from the point of care. In real-time, users at the facility or pharmacy can verify when an order was placed, whether it has been filled and delivered by pharmacy, and who received it at the facility. This is a huge time savings and having an accurate account of inventory on-hand eliminates the need to over order. Risk management – traditional error points in medication administration are eliminated through oneMAR’s built in warnings if a nurse attempts to administer a drug already dispensed or to administer a medication to the wrong resident. The nurse manager is able to review actual medication administration documentation, identify patterns and individual nurse practices rather than relying on what the nurse is “supposed’ to do. Decision support & reporting – reports are available in seconds. Having the ability to export Minimum Data Set (MDS) Section U data saves ~ 312 hours of our nursing time on an annual basis. We also use Catalyst MDS as our Resident Assessment Instrument to improve clinical and operational decisionmaking. We create user defined reports to develop clinical activities based on findings, leading to informed decision-making. One of our goals is to integrate the Indicator Reporting of Accreditation Canada for Clinical Required Organizational Practices into the report module. We provide value-add data |

to our health authority stake holders for policy development and sector planning. Reports include three levels of focus: 1. Resident – quality indicators, i.e. falls, medication use, pressure ulcers etc, resident ages. By identifying residents at high risk of falling based on the number and type of prescribed medications, we can better target specific interventions to minimize risks and improve quality of life. We identify and pay special attention when residents have 9 or more medications which can lead to increased drug interactions, toxicity and side effects; 2. Care / Facility – resource use, management, unit-to-unit comparisons; 3. Outcome Measures – aggregated resident scores, correlations between elements such as depression and cognitive impairment, falls and wandering, mood and activities of daily living; Education and training – training for oneMAR is approximately 20-30 minutes for nursing students and agency staff. Following training, feedback from both of these groups has been positive. oneMAR is seen to enhance practice with accurate documentation, and system speed allows the user to spend time with residents. Staff happiness and retention – our team appreciates the solutions we adopt and how technologically advanced we are…they often “brag” to friends working in other facilities. Have you experienced any unanticipated benefits from adopting oneMAR? oneMAR created excitement amongst staff due to the direct benefit on client outcomes. Creating a healthier workplace environment provided an opportunity for the interdisciplinary professional team to identify workflow improvements to facilitate the medication administration process. Staff engagement, healthcare peer recognition and improved partnership between the facility and pharmacy are all welcome secondary benefits of oneMAR. We expected the scanning to reduce medication errors, however enhanced communication and interaction between the staff and the pharmacy further reduced opportunities for error. oneMAR provides a detailed method of auditing medication administration that ensures quality control measures for the facility and supports the highest standards in resident safety. Training on oneMAR has taken no more than a few minutes before a user can effectively and properly use the system; comprehensive training took 20-30 minutes with both student and agency staff groups who were unfamiliar with the system. Were there best practices identified over the course of your oneMAR implementation that will be adopted elsewhere within your facility as a result of your success? Workflow redesign processes used during the successful implementation of oneMAR eliminated many traditional error points in medication ordering, administration and processing. Risk and quality management audit tools in use by both facility and pharmacy have been refined due to the level of detail now available with oneMAR. Implementation processes used with oneMAR have been applied to identification of other high risk / high error prone activities, i.e. using lessons learned to create and address medication reconciliation. We are conducting a workflow review of the remaining combination of paper / electronic based documentation and accompanying paper forms, in preparation for the implementation of Catalyst’s fully integrated clinical standards based documentation module.

Case study: Three Links Care Society

The successful workflow redesign process has empowered staff to identify other possible improvements to both clinical and support processes promoting advancements for quality resident care. Can you identify areas on which oneMAR has had a positive impact? Clinical workflow and productivity Cost savings Customer service / relationship management Disease management Ease of adoption/training Interoperability Mobility Patient safety Patient satisfaction Quality improvement Reduction of medical errors Can you elaborate on the top three areas of positive impact indicated above? Patient Safety – immediate safety benefits are recognized with oneMAR due to the simplicity and natural follow through of nursing process. For every medication administered, oneMAR enforces the 7 Rights: right drug, patient, dose, time, route, reason, and documentation. oneMAR prompts users to complete each task and eliminates historic “shortcuts” which have always been risk points, i.e. administering and signing later. Resident photos assist regular, casual and agency staff to administer to the right person and simple color coding – red / stop, green / go, ensures maximum safety with minimal training. Nurses quickly check for any missed or omitted medications and either document the reason for withholding or prevent an interruption to diagnosis management by administering; paper based systems did not have a mechanism to identify or require documentation, oneMAR does. Since introducing oneMAR, we have identified previously unrecognized / undocumented error points in the medication administration system. oneMAR has created a major paradigm shift for nursing in medication administration practice and documentation. Clinical workflow & productivity – instead of flipping the pages of a MAR book, reviewing resident medications over multiple pages, and signing for each dose administered, with oneMAR a single scan opens the appropriate resident’s MAR and indicates due medications for that time. All activities are automatically date and time stamped with the user’s electronic signature. Minimal time is required for training, new and casual / agency staff are able to use oneMAR, standardizing the medication administration process and ensuring complete and timely documentation. Quality improvement – by sending pharmacy orders or physician consults from the point of care, we no longer rely on the “old stand-by’s” – sticky notes / scrap paper / nurses hands as reminders, everything is done on the spot. Documentation is improved, meeting the “Gold” Standards of practice with significant impact on the quality of care. Can you indentify areas of maximum impact based on the adoption of oneMAR? Efficiency Productivity Collaboration Access to information Quality |

How did oneMAR achieve improvements in the areas of maximum impact identified above? Efficiency – we estimate 50% time savings; oneMAR ensures a simple, standardized method of safely administering medications resulting in less time on the labor side of administration. Productivity – point of care electronic ordering, inventory management and automated notifications eliminate duplicate communication resulting in labor / time savings for both facility and pharmacy. Collaboration & access to information – for medication reviews, individual’s access real-time data and document feedback remotely, increased physician participation, a partnership approach that improves care. Quality – accurate, timely documentation helps nursing to identify, analyze and use relevant and valid information when making decisions about resident status, i.e. matching an incident with medication intervention, relating diagnosis and symptoms using oneMAR to evaluate effectiveness. With a population of 24% having an active mental health diagnosis and 70% with a stable mental health diagnosis, the mental health team utilizes oneMAR to monitor administration of regular and PRN medications and the timing to impact treatment effectiveness. They used to chase down a nurse with a binder hoping something was recorded! Please identify how oneMAR has contributed to the overall healthcare process and whether you think this solution is replicable within other healthcare organizations. oneMAR point of care medication safety software, coupled with the supporting technology and workflow processes, has improved quality of care, enhanced staff productivity and satisfaction, decreased medication errors and improved resident outcomes. The administration of medication occurs in each and every healthcare setting and specialty worldwide. Historically, medication administration and documentation are some of the most error plagued and time consuming realities of nursing; time constraints often prevent the nurse from spending time with the person in care and practicing both the “art” and “science” of nursing. To have a cost effective solution which leverages technology, is intuitive in its application, reduces workload, promotes quality and reduces risk is an asset to the healthcare provider, system, practitioner and person in care. Our success can definitely be replicated in other healthcare organizations. Although all facilities have their own processes and procedures, the requirements for safe medication practice are the same. Rita – thank you so much for all of your feedback, are you willing to be a reference? I am willing to be a reference, contact me via phone at (604) 434-7211 x502 and I’ll do my best to answer!

Technology Solution Partner: Catalyst Healthcare is a leading provider of medication safety and workflow solutions. TM Through the use of time sensitive bar coding, oneMAR ensures that the right medication is given to the right resident at the right time, increasing safety and efficiency. oneMAR’s inventory tracking simplifies short-cycle prescription delivery, and pharmacies and healthcare facilities (HCFs) benefit from improved communication, extensive reporting, and safe, standardized medication practices . By adding RAI MDS and Dynamic Charting to oneMAR, HCFs have access to a fully integrated, user-friendly tool that supports the highest quality of care. Catalyst solutions are available globally. oneMAR is distributed in partnership with McKesson in North America, and sold, implemented and supported by HD Medi in Europe. For more information, visit www.catalystrms.com.

Case study: Three Links Care Society