Medication Safety - Track # 5
Medication Administration: Innovating Safety Practices
9:35 am - 10:35 am
Integrated Nurse Leadership Program at San Francisco General Hospital
Michael Daly, MSN, NM; Mylene Espiritu, RN; Brandi Lynn Jackson, RN, San Francisco General Hospital
San Francisco General Hospital experienced tremendous results during the Integrated Nurse Leadership
Program (INLP), funded by the Gordon and Betty Moore Foundation, to develop curriculum addressing
frontline practitioners’ leadership and to change management skills, including improvement in medication
administration processes.
The program consisted of:
- A motivated group of bedside nurses, from many different units taking the lead and developing lateral leadership among bedside nurses.
- Data was collected by front-line staff helped to develop ownership.
- Changes to the culture included decreasing interruptions during med passes, wearing sashes, no call zones, flashing light on med cart and adherence to all of the CALNOC med pass standards.
- Leadership buy-in, that was proven to be critical.
Results included a 99% error reduction and a cost savings of over $2.5 million.
UCSF's Integrated Nurse Leadership Program Medication Administration Project (MAP)
Jennifer Pacholuk, RN, BSN; Mary Moore; Sharon Russell; Kathy Walton, UCSF Medical Center
UCSF’s desire was to create a consistently reliable medication process where all nurses are administering
medication in the same exact way, all the time. The Medication Administration Project (MAP) was developed:
- Compares Med with MAR
- No distractions/interruptions during preparation or administration
- Med labeled from prep to administration
- Check 2 forms of ID
- Explain Med to patient
- Chart Med immediately after administration
Medication Reconciliation - Bridging the Gaps in Medication Safety
10:55 am - 11:55 am
Bridging the Gaps in Medication Safety
K. Achanta, MD; Kinzi Richholt; Nsim Karmali, RPh; Qui Van Phan, Washington Hospital Health System
Clinical roles in reconciliation:
- Nurse/Pharmacy Technician –Performs initial intake of home medications
- Pharmacist –Reviews the list for accuracy
- Physician –Uses the list as a basis for ordering medications during the patient’s stay
What we learned:
- Administrative vision was important
- Physician champion and leadership buy-in was critical
- Medical Staff acceptance
- Pharmacy commitment
- Nursing participation
- IT Support
- Resource allocation sufficient to meet project requirements
- Need to communicate…communicate….communicate
Innovation Approaches to Improving the Management of Diabetic Patients
2:20 pm - 3:20 pm
How Sweet It Is: In-patient Blood Glucose Program at Eden Medical Center
Sophie Taylor, RN, BSN, MSHCA; Lisa Quan, RN, BSN, CDE, CPT, Eden Medical Center
**Eden Medical Center Handouts
An Innovative Approach to Medication Compliance
Pat Shakeri, RN, MBA; Nary Sun, RN, BSN, Valley Health Center at Tully
When clinic staff observed diabetic patients with chronic conditions were unable to comply with their prescribed
medication regimen, a simple low cost, RN-run, medication compliance program was developed. Factors
contributing to the inability to comply included self administering multiple medications from multiple containers,
cognitive decline, poor eyesight and multiple system failure requiring numerous medications. The use of a
thirty-day pill box and a simple, one-page form to visually evaluate glucose management were adopted.
Results showed 64.2% of the patients had an improvement in health status as a result of medication
compliance and timely med refill.
Conclusions and future focus:
- 31% decrease in Serum HgbA1C levels in diabetics
- Low rate of hospitalization
- Highest compliance seen in patients with good family support
- Expand medication compliance program to other clinics within the system
Link to complete list of presentations and highlights from the 2010 Exchange
Download a pdf of the complete Highlights of the 2010 Exchange