Submitted by:
Kalev Golubjatnikov MBA, MPH
Leslie A White
(415) 444-4956
Patient Safety and Risk Management
Kaiser Permanente San Rafael
Background
Kaiser Permanente is making a significant investment
in the development and implementation of an
electronic medical record (Health Connect.)
One by one, each of the hospitals in Kaiser's
Northern California Region has made, or is scheduled
to make, the transition to Health Connect. The
transition from care delivery supported by forms
assembled in paper medical chart to care supported
by an electronic medical record is no small
feat. Months of preparation and training, bolstered
by lessons learned from earlier 'Go-Lives' culminated
in a day that dramatically changed the delivery
of health care in the hospital. 'Go-Live' for
Kaiser Permanente San Rafael was November 14,
2009.
Statit piMD used to Monitor Transition
Kaiser San Rafael's transition to the electronic
medical record was facilitated by our choice
to use Statit piMD to monitor indicators of
the progress, and ultimate success, of our launch
into the age of 21st century care delivery.
During the first two weeks of our experience
with Health Connect, Quality Department staff
monitored hundreds of individual items ranging
from elements of the nursing initial assessment
to physicians' use of verbal and telephone orders.
One of our guiding priorities was to focus on
areas that might impact patient safety. To best
convey the power behind the use of piMD during
this important time of transition, allow me
to cite a particular indicator - the use of
bar coding technology and medication management.
Methodology
One of the wonders of the electronic record
is that by virtue of bar coding technology,
we can now insure a match between a specific
medication order (including agent, dosage, route
etc) and the corresponding patient. The pharmaceuticals
are tagged with a bar code as is the patient's
arm band. The potential to virtually eliminate
many types of medication errors is very exciting.
However, like all safety measures, the technology
has to be used properly for it to prevent mishaps.
It seems that at some level it is human nature
to find work-arounds that can render safety
measures ineffective. For this very reason,
we wanted to establish good habits in medication
administration from the start. As a data source,
we ran queries daily to provide detailed information
regarding what we refer to as 'bar code overrides.'
The Statit piMD indicator is calculated by dividing
the number of bar code 'overrides' (either of
the patient arm band or of the drug to be administered)
by the total number of medication administrations.
Data was available not only at the facility
level, but also at the level of the unit and
individual care provider. Our initial goal was
that no more than 5% of medications administered
would be passed without the safety provided
by bar code verification. After a few weeks
of data collection, patterns of behavior and
performance began to emerge. The majority of
staff were highly reliable in their use of the
bar code; a minority seemed to be having difficulty.
We worked together with the managers and educators
to better understand difficulties people were
having and to drive individual and aggregate
performance improvement.
Results
During the first couple of days of implementation,
we were encouraged by aggregate performance
of 6.4% (242 overrides/3790 administrations)
-- not too far from our goal of 5%. By the end
of the 1st full week we had improved to 3.1%
(481 overrides/15,361 administrations.) We further
improved during the month of December reaching
a low of 2% overrides. Since our early experience,
there have been a few weeks where our aggregate
rate has risen and been cause for concern that
we might be back sliding. Invariably, drill
down analysis points to a particular unit or
a few individuals who may have experienced some
difficulty. Given that the data is readily available
to each of the responsible managers, they are
well positioned to investigate and respond appropriately.
This is but one example of how we intend to
harness information to improve quality and patient
safety in our hospital. Statit piMD has helped
our facility manage through an important time
of transition. We are establishing a new culture
of accountability that is supported by convenient,
reliable data presented in a clear and actionable
format.
