case study 4
Despite an established incident reporting system, Medcare Hospital employees were simply not record- ing medication errors in 2013. In fact, only two medication errors were documented between January and September of that year. Either staff was being incredibly diligent in avoiding errors, or a lack of proper data collection meant the hospital’s quality management department (QMD) was not receiving the full picture, and thus patient safety improvement efforts were not being fully supported. This criti- cal question needed to be answered.
About Medcare Hospital
Medcare Hospital is a 64-bed private general medical facility in the United Arab Emirates city of Dubai. Opened in 2007, Medcare employs 577 full-time staff, the hospital has an emergency depart- ment, 25 outpatient consultation rooms, an intensive care unit, a neonatal intensive care unit, delivery suites, an endoscopy room, and a day-surgery unit. The hospital’s QMD was one of the first established in the company to support quality improvement and patient safety functions.
Discovering Unreported Errors
Errors involving patient medication can happen various ways, many creating potentially life-threaten- ing scenarios. If a hospital employee dispenses the wrong medication due to an illegibly written order, or if a nurse gives a medication to the wrong patient, the ramifications can be deadly. Not only does the patient suffer, but the hospital could face legal action and the staff member who made the error could have his/her career derailed as a result. Therefore, when Medcare’s QMD staff learned only two medication errors were reported during the first nine months of 2013—a new low mark for the depart- ment after reported errors had been decreasing in recent years—management determined it imperative to identify what barriers or struggles existed for employees to reporting errors through the existing sys- tem, and what, if any, changes needed to be made.
Given these circumstances, an improvement project focused on medication error reporting was a good fit for the QMD performance improvement program. The program is based on data collection and statistical analysis to evaluate performance, measure outcomes, identify improvement opportunities, and determine priorities. Medcare’s performance improvement activities are prioritized in collabora- tion with the facility’s administrative and clinical leadership. In this case, hospital leaders understood unreported errors could compromise patient safety and inhibit efforts to improve safety results. “Error detection is the first crucial step,” said Shaheena Surani, assistant quality coordinator at Medcare Hospital. “In order to build safer systems, we must be able to learn from previous errors. Reporting discloses medication errors, can trigger warnings, and encourages the diffusion of safe practice.”
Making the Case for Quality
Lack of Reported Medication Errors Spurs Hospital to Improve Data Focus, Patient Safety
• A quality improvement project at Medcare Hospital centered on unreported medication errors.
• A cross-functional team used the FOCUS-PDCA model to determine root causes and identify potential improvements.
• Upon implementing a variety of low-cost solutions, staff members felt more comfortable in reporting errors, thus providing valuable information for building safer systems.
At a Glance . . .
by Janet Jacobsen
June 2015
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Establishing the Project Team
With permission from CEO Ala Atari, Medcare leadership created an improve- ment team to pursue the issue in October 2013. Team members were selected based on their involvement in the error reporting process. Additional members from man- agement were also chosen so they’d be informed of, and involved with, the effort, Surani said. Members of the improvement team included:
• Anu Augustian, head of the pharmacy department
• Abdul Kareem, chief pharmacist • Elizabeth Schulze, chief nursing
officer • Khairunnisa Shallwani, education
and training coordinator, quality department
• Shaheena Surani, infection control coordinator, quality department
• Haitham Naeem, head of the emergency room
• Rejimol Benny, head of general ward two
• Dr. Ammar Hassan, general practitioner
• Bincy Kurian, senior executive, human resources
The nine-member team employed a vari- ation of the plan, do, check, act (PDCA) model known as FOCUS PDCA, which includes the following process improve- ment steps:
• Find the opportunity for improvement • Organize a team • Clarify the current process • Understand or uncover/verify the
root causes • Select the solution(s)
Clarifying the Process, Uncovering Root Causes
Having identified the improvement opportunity and with its project team assembled, the group’s first task was to clarify the error reporting process as it exists, and can be seen in Figure 1.
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Incident occurred
File closed
Action taken
Action taken
Concerned department to close case
Tabulation and data analysis
Immediate action required
Opportunity for improvement
Further action required
Medication error
Form forwarded to the supervisor
Form forwarded to QMD
QMD for data collection
Sent to concerned committee
OVR �lled (MCH-MF-012)
Forwarded to pharmacy for resolution
Improvement planned for
implementation
YES
YES
NO
NO
NO
YES
YES
NO
Figure 1: Current Error Reporting Process
“Despite the existence of (an) inci- dent reporting system, hospital staff did not report most of the medication errors that had occurred. Sources of
errors included: illegibly written orders, dispensing errors, calculation errors, monitoring errors, and administration errors, e.g., giving the wrong medication
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to the patient,” said Khairunnisa Shallwani, quality and train- ing coordinator at Medcare. Given these sources, the project team concluded physicians, pharmacists, and nurses can all be involved in medication errors.
The team then used brainstorming sessions to identify pos- sible reasons for inconsistent error reporting. Once determined, the reasons were plotted on a fishbone diagram, as shown in Figure 2. The causes were divided into four categories: policy, people, process, and plant (work environment). Under these cat- egories, various potential reasons were noted, including: fear of punishment for reporting an error, lack of hospital policy aware- ness, increased workloads, insufficient procedures, an absence of feedback, and regular audits.
Once the reasons for failing to report medication errors were detailed, the team interviewed doctors, nurses, and pharmacists, while also using observation to collect data through gemba walks to confirm or refute the list of suspected root causes. Based on the data collected, the team detailed 14 potential root causes:
• Increased workload • Fear of punishment • Fear of consequences • No regular feedback from pharmacy employees
• Error not considered a reportable error • No pharmacy audit • Lack of process orientation • Low self-esteem • Lack of policy awareness • Lack of interest to report • No risk management program • No system in place • No department head reinforcement • Lack of awareness for medical error reporting
The Pareto diagram in Figure 3 illustrates the number of responses for each of the 14 potential root causes.
Developing and Selecting Solutions
The improvement team proposed 19 solutions, then created a selection matrix to score each solution on the following five criteria points:
• Is it cost effective? • Will leadership support this solution? • Is the solution practical? • Will the solution be accepted by staff? • Is it time effective?
Figure 2: Reasons for Failure to Report Errors Fishbone Diagram
Lack of awareness
No monitoring of policy
No system in place
No time to read policy
Lack of time No online system for
medication administration
Lack of medication tracking
Low self-esteem
Confusion between medication error and near misses
Fear of punishment
Fear of punishment
Fear of legal liabilities
Fear of consequences Effect on performance appraisal
Professional threat Lack of education
Lack of awareness of medication error Fear of punishment
Increased workload and less staff Increased turnover
No supervision during the medication process
No orientation for doctor No process
No requirement
No competency checklist
Error not considered worthy to report
Lack of patient/family education on medication error
Lack of interest
Lack of medication error identi�cation by patient
No audits by pharmacist
Barriers in reporting medication error
Threat of seniors
No risk management program Lack of improvement projects
Lack of standard procedures Fear
No regular feedback from pharmacy
Not aware of the importance
No audit
No enforcement to report error
Ineffective communication No open communication
Fear of consequences/ threat of losing the job
Under-reporting of medication error
Policy
People
Plant
Process
15.76
67.38 74.99
81.51
86.49 89.21 91.93
94.65 97.37 99 100
57.6
44.56
30.43
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Using a weighted scoring system, the team calculated the highest point values, then these solutions were predicted to have the greatest impact on the reporting process. The highest-ranked solutions were then incorporated into the action plan, as detailed in Table 1.
Focusing on Improvement
Many of the solutions in the plan were implemented within a two-month time- frame, while others are ongoing efforts. As noted in the table, nearly all of the solutions were deployed at no cost. The team shared its results with management in December 2013. “Positive feed- back was received on the project,” said Meileen Hoo, a member of the QMD. “Everyone collaborated to know the barri- ers and proposed solutions to improve the reporting of medication errors. All in all, the improvement project was a success.”
Now, the QMD is receiving the critical data it needs to fully understand what’s taking place on its hospital floors. Since staff members have the support systems in place to vent their feelings and anxieties about medication errors, audit schedules are planned in advance, medication error
Table 1 — Solutions Targeted the Root Causes of Underreported Medication Errors
Targeted Improvement Area Plan Cost
Fear of punishment Reduce the extent of punishments None
Error not considered as an error to report/No orientation
• Offer medication safety session to all new hires and a refresher session after three months
• Occurrence variance process flow shared with all units
$3,650 (U.S.
dollars)
Increased workload Proper staffing to help minimize the incident and promote patient safety
None
No regular feedback by pharmacy/less frequent audits
Schedule monthly audits for each unit None
No regular feedback by pharmacy/less frequent audits
Pharmacy must release quarterly action plan for audit results
None
Low self-esteem Empower staff with timely and updated education regarding medication administration and medication safety
None
Low self-esteem Department head advocates for his/her staff and provides support as required
None
Fear of punishment/ consequences
Share medication error cases during unit staff meetings and during medication safety meetings
None
Fear of punishment/ consequences
Provide continuous education per hospital policies and procedures
None
Fear of punishment/ consequences
Encourage medication error reporting with positive feedback and fewer consequences
None
No regular feedback by pharmacy/less frequent audits
• Spot checking by pharmacy for the proper medication usage process
• Provide monthly data regarding medication errors to all unit heads
None
Error not considered as an error to report/No orientation
Department head will review medication error and its type with staff on a regular basis
None
Low self-esteem Provide channels to vent anxieties and fears None
Increased workload Train for effective time management None
Increased workload Ensure mixed-skills staff assignments in all units None
Increased workload • Ensure appropriate staffing • Introduce training for staff plan per unit requirements
None
Low self-esteem • Encourage staff to verbalize their issues on reporting • Head nurse to encourage staff to report
None
Figure 3: Pareto Diagram of 14 Potential Root Causes
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reports are shared on a quarterly basis, and pharmacy department action plans are shared and updated on a regular basis.
As can be seen in Figure 4, medication error reporting has increased since the issue was identified and fully understood by October 2013. Following the first nine months of 2013, which only saw two errors conveyed to management, 49 were reported to superiors in the subsequent 18 months (through April 2015).
Of the 49 errors, 35 were reported in the final quarter of 2013, basically an instantaneous hike from previous employee behavior. But with that quick spike, the reporting rate then took another rather drastic return to previous levels, with only 14 errors reported from January 2014 to April 2015.
Hoo said this was a result of the improvement project, which had dramatically raised awareness, education, and reinforce- ment of proper medication safety for patients. She said it was only natural for employees to improve their work performance and learn how to commit fewer errors, a fact that proves the improvement project as a resounding success.
“The improvement project was a success,” Hoo said, “because of (the) cooperation, communication, and teamwork shown by the members of the team, as well as the staff who were involved.”
For More Information
• To learn more about Medcare Hospital, log on to www.medcarehospital.com.
• If you have specific questions about this project, contact Meileen Hoo at meileen@medcarehospital.com.
• To read additional examples of successful improvement projects in quality, visit the ASQ case studies landing page at asq.org/knowledge-center/case-studies.
About the Author
Janet Jacobsen is a freelance writer specializing in quality and compliance topics. A graduate of Drake University, she resides in Cedar Rapids, IA.
Figure 4: Before and After Incident Reporting
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