Baystate Medical Center, a 653-bed hospital in Springfield, MA, made insulin safety a priority after rolling out its bedside medication bar coding program in September 2008. Staff members continued to see insulin as a problem medication when monitoring event reporting data on medication storage as well as scan rates of medications and patients. Direct observation on the nursing units validated that there were problems with the insulin administration work processes.
"The drug is dispensed as a vial, so it's traditionally handled multiple times for multiple doses," says Gary Kerr, MBA, PharmD, director of pharmacy services for Baystate Health. "There are several issues surrounding the scanning process—the vial can be left unsecured, on the automated dispensing cabinet (ADC) or in another area altogether. Nurses can travel with the vials in their pockets or not return them to the dispensing cabinets rendering the inventory tracking systems useless." The flawed process started with withdrawal of the multi-dose vial from the ADC, included movement through multiple patient rooms for administration of the medication, and ended with numerous temporary disparate storage locations.
Bar-coding at the bedside in itself is designed to manage down medication administration errors. However, in addition to complying with Joint Commission patient safety standards related to insulin, Baystate was struggling with:
- Storage: Accounting for lost vials was a safety concern
- Inventory costs: Accounting financially for lost vials
- Medication scan rates: Scanning each medication vial by barcode
- Nursing administration technique: Using nurses' time most efficiently for medication administration
To resolve the insulin safety problems, the pharmacy leadership team implemented a project to improve Joint Commission compliance, smooth nursing workflow, and reduce the number of potential medication errors associated with insulin.
"This style of approach to patient safety issues is what separates organizations that just want to 'pass' their accreditation survey with those that embrace the concept of ensuring safe patient care every day" says WendySue Woods, RN, MHSA, CSHA, senior consultant for The Greeley Company, a division of HCPro.
Kerr and his team investigated the possibility of affixing a small roll of scannable bar-coded labels to each vial of insulin to control some of the above mentioned issues. Baystate chose two nursing units to pilot test this plan. Both the pharmacy and nursing departments collaborated to come up with the best process for both parties.
The hospital aggressively measured and monitored the data surrounding this process starting in September 2008. After six months, the process was rolled out hospital-wide.
Current practice and results
Today, labels are generated in the pharmacy and then affixed to the vial. When nurses have to retrieve medication order from the ADC, they have everything they need in one place, says Kerr.
"The nurse basically prepares the patient dose at the cabinet, the syringe is labeled right there with the scannable label, and the vial is returned to the ADC, maintaining safety and appropriateness as a high-alert medication," Kerr says. "Then the nurse can go to the patient's bedside with the barcode-labeled dose-ready syringe in hand, knowing that he or she has the appropriate medication and dose."
Nurses no longer travel with multi-dose vials of insulin because the vials do not leave the ADC area. This has resulted in better storage and accountability for insulin vials. Nurses are also reporting higher rates of satisfaction with the process changes.
The facility noted a spike in insulin purchases in correlation with the hospital-wide implementation of bar-coded medications in September 2008. Medication scan rates with insulin have risen dramatically since the hospital started attaching scannable labels to the insulin vials, and the number of insulin purchases has since dropped. The hospital has also realized an unexpected financial savings, a nice added bonus, says Kerr.
"It wasn't really our purpose, but we ended up saving money in insulin inventory costs. One of the particular brands of insulin is $70 a vial," says Kerr.
Success through collaboration
Kerr insists that this process improvement was only possible because both nurses and pharmacists wanted to improve insulin safety. Nursing is in charge of reporting their monthly scan rates. If one unit's reported scan rate is significantly lower than another's for that month, a member of the pharmacy department goes to the unit to discuss the appropriate process and observe medication workflow.
"You can look at all of the reports you want, but until you go up and talk to nurses and watch how they do it, you're really not in a position to recommend process changes," says Kerr. "We intentionally sent a pharmacist to work with key nurses in key areas." Any fixes to the process came from this collaboration, says Kerr, and not from a top-down practice.
Baystate Health has made it a priority as an institution to engage all relevant staff members in an improvement project to ensure optimal outcomes, says Kerr.
"This is a conscious and intentional method of process management and process improvement, the overall company is spreading this staff engagement phenomenon strategically," says Kerr. The insulin safety project is one example of that philosophy in action.
"When disciplines such as pharmacy and nursing work together to improve processes, the patient is ultimately the winner," says Woods.