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Improving Patients Safety with High Alert Drugs Administration
Faculty of Medicine, Ramathibodi Hospital
Thailand

The Problem

Since 2004 the World Alliance for Patient Safety has been now recognized as a global issue. All health care providers must be addressed: how to prevent patients being harmed and quickly to detect patient from unsafe care. Treatment of patients with critical cardiac conditions usually uses many medications, mostly high alert drugs (HADs). As known medication errors and treatment delaying in these urgent critical conditions may cause catastrophic clinical outcomes and life-threatening to patients. Moreover, these drug administration problems may result in morbidity, increase length of hospitalization stay, increase cost, dissatisfaction of patient and family and risk to lawsuit.
The Faculty of Medicine, Ramathibodi Hospital is an academic and tertiary care institute which has 1000 beds and 10 intensive care units. Our cardiac critical care unit (CCU) has 6 beds and services more than 500 patients in each year with serious cardiac conditions. The first error events related to HADs administration was reported in 2005. A 20-year-old female patient was admitted to CCU with cardiac arrest due to congenital prolonged QT syndrome. During the process of care, the patient had hypokalemia and the physician ordered potassium chloride 10 mEq in 0.45%NSS 100 ml infusion within 30 minutes but the nurse prepared double concentration and infused to the patient. After finishing infusion, the patient experienced cardiovascular collapse due to hyperkalemia. The consequence of event was devastating for the patient’s family. This event incited the CCU nurses to discuss with the CCU patient care team (PCT) and plan to establish the HADs team. We started to review database in early 2006 and found that in each year medications administration in CCU was approximately 20,000-30,000 items, of which, 1,500-2,000 items were identified as HADs. The near miss figure of medication was 28 items or calculated into 13.5%, while there were 6 items of medication error or calculated into 2.9% caused by multiple system failure and human error. Root cause analysis (RCAs) was conducted and found that our medication administration process had 11 steps and took 40 minutes from physician ordering to patient and the key factors which lead to mistake and delay of HAD administration are numerous and complicated working processes. Furthermore the whole process was repetitive and lengthy with too much duplication without double checking system or other verification methods and various formulas of the drug concentration. In addition, in the urgent circumstance, the medication errors usually occurred caused by rotating physician and new staff nurses who had no skill and unfamiliar with the HADs. These may cause medication errors in terms of inappropriate dosage leading to inefficient treatment and life-threatening.
From these problems, the CCU of Ramathibodi Hospital established a clinical nursing practice guideline and developed an innovation to identify all HADs and to minimize the risks associated with the use of these HADs since 2007. This initiative implementation reflects the policy of the Ramathibodi Hospital which aims to improve the quality of treatment to be standard and excellent center which will provide accurate, fast and safety treatment to all patients.

Solution and Key Benefits

 What is the initiative about? (the solution)
The key benefits from implementation of this initiative were divided into three categories; patients, working process and personnel.
For the patients, after implementing the innovation, HADs medication error rate decreased significantly. There was no incident of medication error or serious sentinel event in 2010. The patients were safe. They and their families had confident, trusted in care process and had highest care satisfaction. Moreover, using the medication tags that was translated into Thai for the patient’s legibility render him/her to communicate with healthcare providers pertaining to home medication. The process was done during teaching the patient/care giver how to self-manage the medications before discharge.
Regarding working process, more efficient and quicker flow of medication administration was done. Process duration was shortened from 11 steps to 5 steps and, time frame was reduced from 40 to 9 minutes. The innovation reduced working repetition and mistake: providing safe care and less exposure to the risk of lawsuit. Furthermore, this innovation process can ensure transparency, thus, the safety of ever process was verifiable and guaranteed. The practice has been applied with such apparent benefit that it is now a routine practice. It was the first complete cycle of innovation process with specific procedures for HAD that has been supported by international evidence based and has never been implemented in Thailand. This innovation has been adopted and altered by other ICUs inside and outside the organization.
For the personnel’s point of view, this innovation was conducted by multidisciplinary team. Everyone participates in development process as well as designed related tools. Handbook for HADs was created to state the details of HADs in various forms including the type of medications, dosage, side effects, method of calculate drug concentration. Simple and systematic check, double checking tool, evaluation and follow up systems were implemented closely and continuously. Furthermore, improvements and corrections have been done regularly.
After successful innovation implementation, all health care providers; including physicians, nurses and pharmacists, currently aware of patient safety as key indicator and change old working culture leading to alteration in operation of the whole system. This innovation also leads to best practice for both internal and external healthcare providers and become the role model of academic teaching. Finally, this new innovation makes the staffs feel valuable and proud for being part of the success, which provides highest safe care for the patients. It demonstrates excellent service quality in Asia region which corresponds well to the vision of Faculty of Medicine, Ramathibodi Hospital and Mahidol University.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
HADs team led by advanced practice nurse (APN), head nurse, CCU nurses, 2 cardiologists and 1 pharmacist regularly met for finding solution during clinical round and official committee meetings were held on a monthly basis. All the solution providers involved in implementation of the initiative. Patients and the families contributed to the feedback and commented on the sticker colors and the information provided for the patient. Other public hospitals in both Bangkok and rural areas have adopted this innovation to match their organizations and gave feedback for regular improvement of the innovation.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
The main objectives for the initiative were;
• To improve patient safety from receiving HADs through the double checking system in process of medication administration
• To reduced multiple and complicated working process
• To develop procedures in the management of HADs followed the international guidelines
• To adhere with the hospital safety goals and best practice in academic hospital
The strategy for implementing this innovation was done over time. It was led by the team of knowledgeable personnel who acted as mentors for implementation. At the beginning, the staffs were closely followed by mentors to ensure that all the methods/procedures were correctly carried out. However, checking and verifying of documentations, database and medication administration process was still made at every nursing shift.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
1. The HADs team identified the previous problems, reviewed evidence-base guidelines, and brainstormed to propose ideas. After considering all information, we chose the best method and developed clinical nursing practice guideline for HADs management.
2. Systematic checklist and double checking system have been created. These were done by defining and listing HADs. In addition, the checklist and double checking system have been developed for the management of opioids and sedatives in CCU. Then the recorded data was reviewed and analyzed for the potential mistake in order to find solutions.
3. The team created 5 colored sticker tags that labeled HADs for easy identification. The colors are grouped by their mechanisms; for example, red for vasopressors, pink for thrombolytic agents ,yellow for vasodilators, green for sedative agents and orange for antiarrhythmic agents. The colored stickers were applied on the drug tags; intravenous (IV) line, syringe, and infusion pump in order to remind nurses and physicians to handle the drugs with high alert care.
4. The team developed ready-to-use formula HADs tags to reduce mistake caused by manual writing and calculation. Moreover, the labels were in printing forms to eliminate hand-writing copy. Therefore, it was more convenient and reliable. The hospital pharmacy also applies our innovation and developed red color sticker for HADs on the drug tag for both oral and intravenous forms so that the patient and the care nurses can recognize and be extraordinarily careful in using this drug group.
5. To created convenience and accuracy in calculating drug dosage, ready-to-use formula sheet is incorporated in nurses’ and physicians’ folders and a formula label sticker was attached to IV line.
6. Manual for HADs described details of various types and package pictures of HADs, side effects, how to mix and manage the medication solution was made.
7. The prescription receiving process which formerly contained many steps and a lot of manual duplications of order into medication card, kardex, and Medication Administration Record (MAR) was cut down to use only MAR. Instead of manual copying of order, printed stickers with medications detail was used on MAR to reduce time and mistakes of illegible handwriting or misreading, and also include previous medications list and drug allergy.
8. Adjust the method/ innovation of the management of HADs according to the problem/obstacle. So far we have revised for six times.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
1. Developing correct and good clinical nursing practice guideline and innovation was time-consuming since there are many kinds of HADs. So we extensively reviewed the sentinel event articles regarding high-alert medications and patient safety and adopted to our practice.
2. Finding and investing in raw materials used in this innovation (e.g. stickers, paper, and printings) took time and effort as the hospital did not own such resources. We solved this obstacle by asking for funding from the quality development committee and the chief of innovation team
3. It took time to train, educate, and monitor the personnel who involved this innovation, especially for new CCU nurses, rotating physicians and related department personnel. We encouraged and motivated them even though this innovation would change their routine working, but this will improve the final outcome and patient safety.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
The stationary costs (e.g. stickers, quality paper, etc.) were funded by the quality development committee and the chief of innovation team. Brainstorming and development of the system were mainly done by the team, while IT programmer is partly involved in the consultation.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
The innovation process has been sustained since 2006 and the only needed factor is a little financial support. The CEO of Ramathibodi Hospital has announced and supported this innovation practice as a policy for every intensive care unit. In addition, it has been widely adopted in other hospitals, including government hospital and private hospital.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
The highest achievement is the patient’s safety and satisfaction. The implementation requires team work and agreement from all the parties involved which leads to development of unity in the patient care team. Regular and continuous monitoring, evaluation and revision will lead to best policy and work instruction. The beginning of the implementation is the toughest, but successful application will lead to satisfactory result.

Contact Information

Institution Name:   Faculty of Medicine, Ramathibodi Hospital
Institution Type:   Academia  
Contact Person:   Thosaphol Limpijankit
Title:   Assistant Professor  
Telephone/ Fax:   + (66) 2 201 2420
Institution's / Project's Website:   + (66) 2 201 1901
E-mail:   tetlp@mahidol.ac.th  
Address:   270 Rama VI Road, Phayathai, Ratchathewi
Postal Code:   10400
City:  
State/Province:   Bangkok
Country:   Thailand

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