Nurses drive ‘closed loop medication administration’ success

TORONTO – The North York General Hospital (NYGH) “closed loop medication administration” system, or CLMA for short, is helping NYGH rack up some impressive benefits, including:

• Preventing over 2,300 medication errors in the first year of implementation – in conjunction with other elements of NYGH’s advanced EMR, including its computerized provider order entry (CPOE);
• Achieving a 95% barcode scanning compliance rate for the 110,000 doses the hospital scans on average per month;
• Raising adverse-drug event prevention accuracy rates, in physician medication reconciliation of admission and discharge records, from an average of 8% to over 80%;
• Improving turnaround time for STAT medication orders for serious and life-threatening cases by 83%.

“It’s important to know that CLMA is part of a broader clinical information transformation project, we call ‘eCare’, that the hospital has been undertaking since 2007,” says Sumon Acharjee, the hospital’s Chief Information Officer, who joined NYGH in January 2015.

The clinicians’ e-care efforts made NYGH the first community academic hospital in Canada to climb to Level 6 certification of what’s called the HIMSS EMR Adoption Model (EMRAM).

Now NYGH and CIO Acharjee are preparing to reach the very peak of EMRAM certified approval, Level 7.

“NYGH didn’t start its eCare project with the specific goal of being certified by EMRAM, but it’s a bit of serendipity that EMRAM criteria and our eCare objectives of excellence in providing patient-centred, safe, high-quality healthcare are all aligned,” says Acharjee.

Patients coming in through NYGH’s automated front doors are entering a hospital that has demonstrated fewer preventable errors, better adherence to best practices and lower patient mortality rates than many others.

What they may not know is how much of those patient benefits are thanks to its nurses and their dedication, especially to reducing medication errors.

Former director of clinical informatics, Sonia Pagliaroli, an 18-year NYGH veteran who began there as a labour and delivery nurse, was instrumental in the development of the hospital’s Wireless on Wheels computer carts that assist nurses on their shifts.

The WOW’s hand-held bar-code reading scanner crucially closes the loop left open in paper-based prevention techniques of the past. It does so by confirming electronically that a medication, with a certain dosage, at a specific time for the right patient is, indeed, the intended and correct one.

Linna Yang, is now taking the interim lead on new CLMA developments at NYGH.

Yang, a former cardiac nurse, capped nine years of hospital informatics work with an MHI degree in the subject before putting both her clinical experience and technical expertise to work at NYGH three years ago.

“We use our clinical knowledge to bridge the gaps between the clinical world and the IT world,” says Yang. “We make sure whatever we implement fits the clinician’s workflow.”

While Yang knows how much nurses have contributed to NYGH’s admirable climb up the e-health heights, she’s quick to point out they should not overshadow contributions of other clinical mountain climbers: “To have our CLMA work, we need physicians, pharmacists, all our allied health partners, and we need IT people to connect everything. We need a full team.”

Despite rising awareness of medical errors in general, and medication mistakes in particular, such mishaps continue in the healthcare system. In the United States, the landmark 1999 study, To Err is Human, estimated that up to 98,000 Americans die each year as a result of medical errors.

More recent reports, including one published this year by researchers at Johns Hopkins Hospital, suggest there are as many as 250,000 medical error deaths annually, making them the third leading cause of death in the country.

A Canadian study done over a decade ago, by researchers at the University of Toronto, suggested some 23,000 Canadians die each year from clinical miscues.

While work still needs to be done on the causes of medical errors, one major reason is well known: interruption. It is something even dedicated nurses are prone to.

“The problem is nurses are very busy people,” observed Pagliaroli before departing NYGH. “But while they are trying to give the best care they can, they are constantly being interrupted – and that’s when adverse events like medication errors can occur.”

So now, brooking no interruptions is a best-practice at NYGH, especially while nurses are engaged in patient care using CLMA software supplied by Cerner, bedside hand-held scanners by Zebra (formerly Motorola) and WOW carts by Rubbermaid.

Because every nurse has a cart while on a shift, they are never interrupted by another nurse borrowing it. The nurses use the system’s hand-held scanner at the bedside to read the bar codes on the medications, as well as the codes on patients’ arm bands to confirm that all is in order.

The all-electronic system closes the loop-holes scooted through in the past by hand-written paper forms, unrecorded verbal orders, and manual interventions.

“If you don’t have a CLMA system in place, you not only have physicians’ handwritten orders and others manually transcribing the medication record. The pharmacist must also read the record and manually dispense the order,” observes Yang of places where medical errors can blossom. But worse yet: “Without CLMA, when the medication reaches the floor there is no final check for errors.”

Yang admits CLMA can, despite being all electronic, slow things down.

“It does take more time for doctors to put their orders in the system, but once they do, there’s less potential for error. When the doctor writes the order, the nurse sees it, the nurse scans it, and automatically charts it. That’s what’s considered a closed loop,” says Yang.

But all that wasn’t put in place at NYGH overnight to immediate applause.

Pagliaroli, Yang, and their team didn’t take technology offered to them by vendors, and just plunk it in and say here it is so go use it. To start with, they staged an introductory event with NYGH nurses and pharmacists and asked questions like: How do we currently give medications? What are the problems with this process? Then all together they started to map out future visions of designing and implementing the best possible CLMA system for NYGH.

After that foundational event, NYGH’s informatics team staged simulations and got the devices into nurses’ hands in a “Device Fair” where they were encouraged to try the various types of software and hardware and to also suggest improvements.

But it wasn’t these successes that gave final shape to NYGH’s CLMA. Rather it was failure, or rather the fear of it.

They did what is known as a FMEA, a failure mode and effect analysis. In this session, the CMLA team asked themselves: What’s every possible thing we can think of that could go wrong?

After listing all such points of possible failure, the FMEA process calls for scoring the probability and severity of each potential problem and then ranking them. You then devise a “mitigation plan” for each to reduce the chance of that problem ever arising.

In future, NYGH’s closed loop medication administration system promises to get even smarter about how it works and who uses it. Currently, the CLMA does not reach into the Emergency Department – where its benefits could be extended.

As always, NYGH will scale the informatics heights by small, carefully considered steps: “We always do incremental improvement; we learn; then we optimize; we make sure the technology does not get in anyone’s way; and we do plenty of training before anything is ever implemented.”