1

We Heal, We Teach, We Discover, We Care

Developing a Medication Safety Strategic Plan

Marc R. SummerfieldDirector of PharmacyUniversity of Maryland Medical CenterTimothy J. Babineau MDSenior Vice-President, Chief Medical OfficerUniversity of Maryland Medical Center

Maryland Patient Safety Center Fourth Annual Confer enceBaltimore, Maryland Thursday, March 20, 2008

Outline

• Overview of the Medical Center

• Overview of Pharmacy

• Why do a Strategic Plan?

• Assessing Current State

• Developing a Strategic Plan

• Execution

2

University of Maryland Medical System

University of Maryland, BaltimoreUniversity of Maryland, Baltimore

School of LawSchool of Law

School of Social WorkSchool of Social Work

School of DentistrySchool of Dentistry

School of PharmacySchool of Pharmacy

School of NursingSchool of Nursing

School of MedicineSchool of Medicine

Professional Schools

University Physicians, Inc.Faculty Practice Plan

University Physicians, Inc.Faculty Practice Plan

University of Maryland Medical System

UMMS Board of DirectorsUMMS Board of Directors

University of Maryland Medical Center

University of Maryland Medical Center

University Hospital

Greenebaum Cancer Center

Shock Trauma Center

Programmatic Joint Ventures

UniversityCARE, LLCUniversityCARE, LLC

The University of Maryland Medical System (UMMS) is governed by a board of directors and is neither owned by the State of Maryland nor governed by the University of Maryland. The University of Maryland Medical Center (UMMC) is a private, not-for-profit hospital,

serving the State of Maryland and Baltimore City with a full continuum of services. UniversityCARE is a partnership between UMMC and University Physicians, Inc. operating primary care centers in West Baltimore and multispecialty satellites.

6,031 Employees

689 Licensed Beds

32,278 admissions

551 ADC

5.6 ALOS

155,000 outpatient visits

18,095 Surgeries

64,458 ER Visits

General

Founded in 1823 as the Baltimore Infirmary, the University of Maryland Medical Center is one

of the nation's oldest teaching hospitals. Located on the west side of downtown Baltimore, the Medical Center provides highly specialized tertiary and quaternary care for the entire state

and region and comprehensive care for the West Baltimore community. UMMC provides a

broad range of inpatient and outpatient services and functions as the primary teaching

hospital for five professional/graduate schools of the University of Maryland.

Medical Staff

All members of the medical staff at UMMC are members of the faculty of the School of Medicine or the School of Dentistry. The majority of the active admitters to UMMC are

salaried full-time faculty of these schools. As of January, 2008, there were 1,071 clinical

faculty on the medical staff.

Services Provided

UMMC offers a broad range of primary, secondary, tertiary and quaternary services

complemented by extensive education and research activities. In addition to meeting the medical needs of its immediate service area, UMMC serves as a tertiary and quaternary

referral center for the State and Mid-Atlantic region and considers itself a national leader in

the following specialties: solid organ transplantation, bone marrow transplantation, trauma

care, cardiac care, oncology, neonatal and high risk obstetrics, and innovative laparoscopic

surgery.

University of Maryland Medical Center

3

Pharmacy Overview:

• Pharmacist FTEs (including managers and clinical specialists): 83

• Technician FTEs: 105

• Support Personnel FTEs: 12

• Number of Unit Doses Per Day: ~15,000

• Number of IV Admixtures Per Day (including first do ses manually picked): ~900

• Omnicell® Doses Per Day: ~11,200

• Robot Picks Per Day: ~4000

• Number of TPNs Per Day: ~ 50

• Drug Cost Per Day: ~ $170,000

Pharmacy Overview: Centralized/Decentralized Model

– Centralized Operations:

• IV Admixture (Intellifill®);

• 24-hour cartfill (McKesson Robot-Rx®);

• Compounding/Repackaging

– Decentralized Satellites:

•Women’s & Children’s (“Peds”); Greenebaum Cancer Center (2); Gudelsky; Weinberg; Shock/Trauma; O.R. Pharmacy

– Omnicell® unit-based cabinets:

• 144 cabinets including Anesthesia Carts for O.R.’s

4

Pharmacy Overview: Heavy Focus on Technology

• Cerner PharmNet Millennium®: CPMOE*CPMOE*

• Omincell® Unit-Based Cabinets with Safety StockSafety Stock ®®**

• Omnicell® Anesthesia WorkStations

•• McKesson RobotMcKesson Robot --RxRx®®** and Intellifill®

• TUGs®

•• IV TrackIV Track ®®:: bar-coded matching of patient label with pre-mixed IVs

• QS/1 NRx® Ambulatory Care Software

•• ScriptProScriptPro ®® Ambulatory Care RobotAmbulatory Care Robot

• WebFormulary® and WebIDS®

• VasTech Scheduling Software®

• Medication Area Inspection Database: Medkeeper®

• Pharmacy OneSource® Quantifi®

• Valimed® controlled substances waste verification

Why do a Strategic plan?

• Improves organizational focus among all stakeholders

• Promotes collaboration across the entire organization

• Defines measures of success and failures

• Translates strategies into programs, projects and products

• Fosters accountability among participants.

5

To Err is Human: Building a Safer Health System

• IOM releases report : 11/99

• Deaths due to medical errors are between the 4th an d 8th leading cause of death in the United States.

• Medication errors account for > 7000 deaths/year(incorrect prescribing or dispensing of drugs)

• Almost 2% of admissions experience adverse drug event

• Increased hospital cost of $4,700 per ADE.

Medication Safety will remain one of the majorpatient safety challenges of the next decade

The Five Tasks of Strategic Planning

• Developing a Vision and a Mission

• Setting Objectives

• Crafting a Strategy

• Implementing and Executing Strategy

• Evaluating Performance, Reviewing the Situation and Initiating Corrective Action

6

Three Big Strategic Questions

• Where Are We Now?

• Where Do we Want to Go?

• How Will We Get There?

Or . . . What is the “goal”?

Strategic Planning

•A vision with a task is but a dream

•A task without a vision is drudgery

•A vision and a task can change the world.

From a church in Sussex, England. C. 1730.

7

What is the goal? What is our Mission and Vision?

• Mission: To provide standard-setting, proficient, and compassionate pharmaceutical care services to the patients, health care professionals, and employees of the University of Maryland Medical Center.

• Vision: To become a national leader in developing innovative methods for ensuring the safest medication practices anywhere.

Nine priority areas of focus that contribute to our mission• Create, communicate and demonstrate a leadership-dr iven

culture of safety.

• Improve error detection and reporting and use of th e informationto improve medication safety.

• Optimize control and storage of medications for med ication safety (including purchasing).

• Design and execute the Prescribing function to opti mize medication safety.

• Design and execute purchasing and Dispensing (inclu ding delivery process to optimize medication safety).

8

• Design Medication Administration process to optimiz e medication safety.

• Enhance the quality and accessibility of medication -related information and the communication of information to optimize medication safety.

• Standardize protocols and processes to optimize saf ety. Optimize medication safety for special patient popu lations (pediatrics/oncology).

• Maintain and improve existing processes and program s that contribute significantly to medication safety.

Nine priority areas of focus that contribute to our mission

Planning a Strategic Planning Retreat

• Multidisciplinary

• Off-site

• All Day

• Guest Speaker

9

Program: December 15, 2006• Welcome and Purpose: Marc Summerfield

• Building a Culture of Safety: Dr. Tim Babineau

• Medication Errors: a Review: Kasey Thompson, ASHP

• Applying Automation for a Safer Medication Use Process:

Mark Neuenschwander

• Models and Principles of Medication Safety: Marc

Summerfield

• Role of Human Factors in Patient Safety: Jake Seagull, PhD

• CPMOE: Update

• MEADE: Three Years of Accomplishments and Lessons

Learned

• Work sessions throughout the day on the nine priority areas

University of Maryland Medical Center Pharmacy Department

Medication Safety

Strategic Plan

10

•Appoint a point-person (leader) for the Medication Safety Strategic Plan.Status: Done: Susan Carey, Professional Development Coordinator.

•Appoint a nurse medication safety champion; we have physician champions (CMO; Co-chair of MEADE) and a pharmacy and overall champion (MSO).Status: Done: Ronetta Lambert, RN.

Create, communicate, and demonstrate a leadership-driven Culture of Safety

1

Create, communicate, and demonstrate a leadership-driven Culture of Safety•Evaluate the hospital’s mission/vision/values statements to accurately reflect the strategic emphasis on patient safety, including medication safety.

Status: Done: Values statement is expressed by our “Commitment to Excellence”program—where ”Safety and Quality”is one of the five pillars.1

11

Create, communicate, and demonstrate a leadership-driven Culture of Safety•Disseminate the “Striking the Right Balance”model to depict the challenge in achieving the proper balance between Medication “Control”(Safety/Security/ Compliance) issues and “Access” (Timeliness/Convenience/Flexibility) issues.

1 Goal: To Achieve the desired level of Control of medications without sacrificing Access to medications.

Control

Compliance

Security

Safety

Access

Convenience

Timeliness

Flexibility

Achieve the desired level of Control of medications

without sacrificing Access to medications.

Striking the BALANCE in Medication Use

1

12

Improve Error Detection and Reporting and use of the information to improve

medication safety.

•Install an on-line medication error and adverse drug event reporting hospital-wide. Status: Done: RiskMaster® linked to MedMarx®.

2

Improve Error Detection and Reporting and use of the information to improve medication safety.

•Investigate use of the observational methodology to enhance medication error detection during drug administration and to establish a credible medication error rate for trending and benchmarking.Status: Pursuing AU Meds®.2

13

Optimize Control and Storage of medication safety (including purchasing).

•Implement barcode-based Omnicell Safety Stock®automation hospital-wide to improve accuracy of Omnicell® stocking and withdrawing and returning.Description: SafetyStock™—a patient safety feature for preventing restock, issue, and return errors; uses bar code scanning as a secondary checking methodology for tracking medication ingress and egress from the system. Status: Expanding PICU Pilot.3

Optimize Control and Storage of medication safety (including purchasing).

3

14

Design and execute the Prescribing function to optimize medication safety.

•Pursue e-prescribing for discharge and clinic-based at-home-use medications.

Status: The Epic® portfolio project is in final stages of purchase and integration of the Sure Scripts®product, which does e-prescribing. This is the solution for ambulatory care and the future solution for discharge. 4

Design and execute the Prescribing function to optimize medication safety.

•Implement Computerized Prescriber Medication Order Entry.

Status: Done!Fully-integrated/linked: universal access; prescriber order entry with electronic pharmacist order verification; access to lab data; access to non-medication orders (diet, wound care), and e-MAR.

4

15

Design and execute purchasing and preparation and Dispensing process (including delivery) to optimize

medication safety.

•Expand Robot-Rx® functionality to dispense 50% of all first doses from the Robot by July 2008.

Status: Pilot. Implement “forcing function.”5

Design and execute purchasing and preparation and Dispensing process (including delivery) to optimize

medication safety. •Install Carousel® or Intellishelf® technology to improve accuracy of selecting manual (non-Robot-Rx® selected) medications (inhalers; otics; ophthalmics) for the cartfill supply.

Status: Pursuing.5

16

Design and execute purchasing and preparation and Dispensing process (including delivery) to optimize medication safety.

5

Design Medication Administration process to optimize medication safety.

•Prepare for installation of Barcode Point-of-Care Medication Administration.(BPOC-MA).

Status: Preparations: On-going. Plan Pilot at University Specialty Hospital.

6

17

6

•Limit the number of locations that store medication for patient administration.

Status: Plan Six Sigma Exercise.Guiding through directional language in e-MAR (“Usually located in Omnicell®”).

Design Medication Administration process to optimize medication safety.

Enhance the quality and accessibility of Medication-Related Information and the communication of information to optimize medication safety. •Evaluate current situation regarding the provision of multi-lingual, patient-based medication instructions and information.

Status: Pursue QS/1 “add on” program, which allows the identification of Spanish-speaking patients and which produces patient instructions and drug monographs in Spanish.

7

18

7

Develop process to display patient-specific pregnancy and lactation information during prescribing.Status: Current state: Pregnancy and lactation status is documented electronically on admission on the Intake/Triage Form. Desired Future State: Pregnancy and lactation status would appear on each screen during prescribing and verifying of medication orders, so this information is easily accessible to those involved in medication management. Drugs with a category "X" classification would prompt an alert to prescribers and pharmacists.

Enhance the quality and accessibility of Medication-Related Information and the communication of information to

optimize medication safety.

Standardize protocols and processes to optimize medication safety. Optimize medication safety for special

patient populations (pediatrics/oncology).

Develop, maintain, monitor, and improve medication reconciliation process. Status:

Fully integrated into CPMOE.Able to electronically track compliance.Working to create electronic tools for prescribers, such as a computer-generated medication list upon discharge.

8

19

Standardize protocols and processes to optimize medication safety. Optimize medication safety for special

patient populations (pediatrics/oncology).

•Develop and perform medication safety assessment (gap analysis) of best practices versus actual for cancer chemotherapeutic and pediatric agents. Develop action plan.

Status: Completed gap analysis for cancer chemotherapeutic agents; assembling action plan.

8

Maintain and improve existing processes and programs that contribute significantly to medication safety.

•Standardize drug references in all patient care areas. Supply most recent editions. Replace manual versions with electronic versions if possible.

•Sustain an active and effective Medication Error and Adverse Drug Event (MEADE) committee.

•Sustain integrity of philosophy of using generic nomenclature as the preferred drug nomenclature.

9

20

Maintain and improve existing processes and programs that contribute significantly to medication safety.

•Continue to standardize and limit the number of intravenous and oral drug concentrations.

•Continue to promote pharmacy review of medication orders before administration.

•Sustain “Omnicell® philosophy”: Minimize storage of non-emergency floor stock medications on the patient care units.

9

“Whatever you are, be a good one.”

University of Maryland Medical Center