Kaiser Permanente’s MedRite Protocol A Medication Administration Innovation

Alyssa Morita, RN, BA, BSN Presenter Cecelia Crawford, RN, MSN Quincyann Febre, RN, BSN Co-Presenter Alternate Presenter

Kaiser Permanente Southern California Nursing Research Program

It all began with a question… What is the quality of evidence for each step of the Kaiser Permanente MedRite Protocol in the acute hospital setting?

Kaiser Permanente MedRite Protocol: Context Institute of Medicine (2006) report on prevalence of medication errors in US:  Cause 7,000 deaths every year  1.5 million people annually are harmed  1 medication error per day per hospital patient  >$3 billion each year treating medication injuries

Integrative Review: Purpose & Aim To review the quality of evidence for each step in Kaiser Permanente’s (KP) MedRite Protocol used by nurses in the acute care hospital setting Provide recommendations to nurse executives, nurse managers, nurse educators, & staff nurses

Kaiser Permanente MedRite Protocol: An Overview To enhance patient safety during medication administration rounds in the hospital setting by utilizing: a standardized RN workflow

and non-interruption wear

KP KP Medrite Medrit

e

Do Do Not Not Disturb Distur b

MedRite 10 Step Protocol Step 10: Nurse removes sash Step 9: Charts medications in patient room

Step 8: Opens med blister pack in patient room Step 7: Asks patient if there are any questions Step 6: Explains medications to patient Step 5: Checks 2 forms of identification Step 4: Turns TV and radio volume down Step 3: Performs hand hygiene in patient room Step 2: Compares medication with MAR Step 1: Nurse puts on sash

Integrative Review Search Strategy A 2004-2009 review of the research evidence via electronic databases examined each step of the MedRite Protocol, with separate searches for each step General topic of interruptions & distractions captured via contextual links

Synthesis of Evidence Total Articles Reviewed: 1122 Relevant Articles: 12 Majority of reviewed evidence based on expert commentary, guidelines, & integrative or literature reviews Distinct lack of evidence supporting separate MedRite components Final grade of insufficient for body of research evidence

Key Research Study (Pape, 2003) Quasi-experimental study to test 2 interventions designed to decrease nurses’ distractions: • Focused protocol = checklist • Visible sign of med administration = vest

Results: Med administration protocol involving a checklist & visible symbol worn during medication rounds was effective in reducing nurses’ distractions

Evidence Summary 10-Step MedRite Protocol Standard medication policy:   

Verify meds with MAR(9,10) Check 2 forms of ID(7,9,10) Document meds given at bedside(9,10)

Teach patients about meds & allow time for questions(3,7,9,10) 

Recommended part of med administration process

Conflicting literature results on hand hygiene and prevention of healthcare associated infections(1) Expert opinion advocates for diligent hand antisepsis(6,12)

Summary of Evidence Interruptions & Distractions MAEs are due to failures in environmental and system factors/processes, rather than individuals(4,5) Distractions & interruptions are ill-defined(4,8,9) No direct link between task interruption & med errors(7) Nurses felt frequent interruptions contributed to med errors(7) Nurses do not have a suitable environment to guarantee patient safety(8)

Interruptions are (2)  Short  Communication oriented(2,9)  Initiated by nurses or other team members(2,8,9)

Conclusions Although parts of MedRite protocol are innovative, the majority of the steps align with current regulatory guidelines, as opposed to any body of evidence General topic of medication administration represents a dense area of literature, with resulting evidence generating more questions than provides answers

No link can be made between implementation of a standardized medication administration protocol (MedRite) and patient related outcomes (MAEs)(4,5,9)

Recommendations for Consideration Staff Nurses Rely on best evidence, rather than rituals, policies, & procedures, to prevent MAE(7) Establish strong nurse- Educational interventions & patient partnerships to teamwork to distractions(4,9) safeguard against med WASH YOUR HANDS before errors(3,10) direct patient contact(1,6) Educate patients about Take accountability for one’s their meds at each (7) own nursing practice (3,10) encounter

Recommendations for Consideration Nurse Managers/Executives Maximize patient safety by implementing defense barriers & developing a practical med policy(2,7) Be aware of work interruption characteristics in order to develop evidence-based systems and interventions to reduce interruptions(2,4) Create a calm and quiet medication administration environment to enhance patient safety(7,8)

Recommendations for Consideration Organizational Leadership Develop med admin processes that emphasize systems factors, rather than individual blame(5) Support a calm & noise-free environment(2,4,8,9)

Create evidence-based med admin protocols according to local regulations, settings, needs, & resources(12)

Implement a system that evaluates linkage between patient outcomes + med admin protocols(5)

Provide the VISION needed to generate a culture of patient safety & safe med admin(9)

Future Nursing Research Investigate use of visible symbols to safeguard nurses during med admin (9) Replicate Pape’s 2003 study(9) Examine linkage between work interruptions & medication errors(2) Study impact & effectiveness of various med admin safety interventions(8)

Additional Research Westbrook et al., 2010(11) Hypothesis: Interruptions during med admin increases errors Results: Each interruption associated with  12.1% increase in procedural failures  12.7% increase in clinical errors  Nurses experience was no protection against making a clinical error & was associated with higher procedural failure rates

Conclusion More interruptions nurses received = greater number of clinical errors.

Acknowledgements We wish to thank:

Anna Omery RN, DNSc, NEA-BC

Cecelia Crawford RN, MSN

June Rondinelli RN, MSN, CNS

for their endless support and dedication to the completion of this project

Contact Information Alyssa Morita, RN, BA, BSN Research Resident KP West LA Medical Center (323)857-3571 [email protected]

Quincyann Febre, RN, BSN PICC Line Nurse KP West LA Medical Center (310)383-4349 [email protected]

Cecelia Crawford, RN, MSN Project Manager III KP SCAL Nursing Research Program (626)405-5802 [email protected]

Questions

References 1.

2.

3.

4.

Backman, C., Zoutman, D. E., & Marck, P. B. (2008). An integrative review of the current evidence on the relationship between hand hygiene interventions and the incidence of health care-associated infections. American Journal of

Infection Control, 36(5), 333-348. Biron, A. D., Loiselle, C. G., & Lavoie-Tremblay, M. (2009). Work Interruptions and their contribution to medication administration errors: An evidence review. Worldviews on Evidence-Based Nursing,6(2), 70-86. Committee on Identifying and Preventing Medication Errors, Board on Health Care Services (2007). Preventing medication errors, Philip Aspden…[et al.], editors. Institute of Medicine of the National Academy of Sciences, 1-481. Fry, M. M., & Dacey, C. (2007). Factors contributing to incidents in medicine administration. Part 2. British Journal of Nursing, 16(11), 676681.

References 5.

6.

7. 8.

Hughes, R. G., & Blegen, M. A. (2008). Chapter 37: Medication Administration Safety. In R. G. Hughes (Ed.), Patient Safety and Quality: An Evidenced-Based, Handbook for Nurses, Chapter 37, 1-61. Agency for Healthcare Research and Quality. Retrieved from http://www.ahrq.gov/qual/nurseshdbk/ Morbidity and Mortality Weekly Report (2002). Guidelines for hand hygiene in health-care settings: Recommendations of the healthcare infection control practices advisory committee and the HICPAC/SHEA/APIC/IDSA hand hygiene task force. Centers for Disease Control and Prevention, 51(RR-16), 1-44. O’Shea, E. (1999). Factors contributing to medication errors: A literature review. Journal of Clinical Nursing, 8, 496-504. Palese, A., Sartor, A., Costaperaria, G., & Bresadola, V., (2009). Interruptions during nurses’ drug rounds in surgical wards: Observational study. Journal of Nursing Management, 17, 185-192.

References 9.

Pape, T. M. (2003). Applying Airline Safety Practices to Medication Administration. MedSurg Nursing, 12(2), 77-93. 10. Smetzer, J. (2001). Medication error prevention techniques for the bedside nurse. Hospital Pharmacy, 36(6), 588-589. 11. Westbrook, J. I., Woods, A., Rob, M. I., Dunsmuir, W. T., & Day, R. O. (2010). Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med, 170(8), 683-690. 12. World Health Organization (2009). World Health Organization (WHO) guidelines on hand hygiene in health care: First global patient safety challenge – clean care is safer care. WHO Press. Geneva: Switzerland.