Eliminating Workarounds Prevents Medication Errors

It is key as a quality improvement person to, upon finding an issue with the EMR or dispensing machines, involve the end users to identify why the problem is happening.

One of the biggest problems CVMC has discovered is workaround issues surrounding core measures and influenza and pneumoccal vaccinations.

"We've found by looking at the Pyxis logs that there are ways that are legitimate in finding that these vaccinations don't need to be given," says Sharp. "We're trying to standardize the process, make sure everyone is educated."

CVMC is examining Pyxis logs, has involved a nurse vaccination team, and included pharmacy and IS to address this ongoing issue.

"We've identified these workarounds as part of the vaccination issue, but it's bigger than that, and it has helped us," says Sharp. "The abstractors have identified the problem, and sat down with a multidisciplinary team to address the issue."

This process has actually helped to resolve other issues as well. The first involves vaccinations and scheduling on the MAR. The MAR has vaccinations at 2 p.m.

"If you've got a patient going home in the morning, those doses can be missed," says Sharp.

To fix this, an alert has been implemented as part of the discharge checklist, requiring the nurse to verify the status of the patient's vaccinations.