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SEATTLE - (March 10, 2011) — Virginia Mason Medical Center honored 29 team members at the sixth annual Mary L. McClinton Patient Safety Award ceremony today for their work to prevent adverse drug events (ADEs) through hospital medication reconciliation.

The prestigious organizational award is given during National Patient Safety Awareness Week each year to a deserving team in memory of Mrs. Mary L. McClinton, who died at Virginia Mason in 2004 due to a preventable error. Her life and untimely death are an inspiration to staff to do everything possible to eliminate avoidable death and injury at Virginia Mason.

At the award ceremony, attended by members of Mrs. McClinton's family, Virginia Mason Chairman and CEO Gary S. Kaplan, MD, explained, "Every day our resolve to be the safest hospital grows even stronger. This occasion reminds us of the profound importance of ensuring a system that takes the potential for human error out of the equation. Mrs. McClinton and her friends and family are with us every day in our hearts and minds as we stay true to our promise of safety."

The challenge of hospital medication reconciliation
Drugs cure disease, relieve symptoms and ease pain. Unfortunately, they can also harm people when administered at the wrong time, in the wrong amount or in the wrong combination. Adverse drug events (ADEs) are the single largest source of medical errors, resulting in 7,000 deaths annually in the United States. They occur in 6.5 of every 100 hospital admissions with 42 percent being serious or life threatening. ADEs are also expensive, costing $4,700 per admission.

To prevent ADEs associated with hospitalization, a patient's medications must be "reconciled," that is, medications being taken at home, prescribed during the stay and at discharge, must be accurately listed and compared to prevent errors and ADEs. A key to successful medication reconciliation is communicating an accurate medication list to patients, family members, and caregivers.

How did the team achieve success?
Virginia Mason began its focused work on solving the ADE challenge in 2004 by forming a cross-functional, hospital-based Medication Reconciliation Team that included members from hospital medicine, emergency, critical care, rehabilitation, information systems and leadership.

Because Virginia Mason did not have an electronic prescribing tool designed specifically for medication reconciliation, team members began by using an electronic progress note with checkboxes next to each medication indicating the plan to stop, continue or change the medication. This was the best solution available in 2006, but it was complex and prone to human error — especially errors of omission.

The team used feedback and coaching to improve the process. Frequent individual coaching, retraining and repetition of purpose and meaning changed the culture. The team began to see physicians and pharmacists using the medication reconciliation clinical notes to communicate reasons for stopping and changing home medications. By April 2008, Virginia Mason was sustaining 90 percent reconciled medications on admission.

But 90 percent was not nearly close enough for a team striving for perfection. In 2009, several improvement workshops helped physicians, nurses, pharmacists and patients understand individual roles in building an accurate medication list; improved communication and signaling to each other to reduce re-work; and redesigned the discharge medication reconciliation process to ensure a defect-free medication list was created and received by all patients and caregivers.

In 2010, the team focused on perfection with new electronic prescribing tools specific to medication reconciliation. They conducted more workshops to implement the new electronic functionality into the Computer Provider Order Entry (CPOE) system. The new tool went live Nov. 2, 2010. Now medication ordering and reconciliation are combined into one single step, and every medication requires a deliberate decision to continue, change or stop.

"The entire organization has demonstrated commitment to continuous improvement on medication reconciliation, and this team has achieved significant results," says Cathie Furman, RN, senior vice president, Quality and Compliance. "Our work will not be complete until we have achieved our goal of zero preventable adverse drug events, but I'm so proud of this team for all they have accomplished."

Achievements

  • Admission Medication Reconciliation: In 17 of 18 audits posted since April 2008, Virginia Mason has sustained 90 percent or more medications reconciled upon hospital admission. In November 2010, a one-time audit of the new electronic tool indicated an admission medication reconciliation rate of 100 percent (N = 810 medications).
     
  • Discharge Medication Reconciliation: Virginia Mason has sustained 90 percent or more medications reconciled upon hospital discharge since January 2010. In November 2010, repeated audits of the new electronic tool indicate sustained discharge medication reconciliation rate of 100 percent.
     
  • Standard Work and Role Clarity. Virginia Mason implemented standard work for emergency department nurses, inpatient nurses, physicians and pharmacists, which includes signaling that identifies the check was completed. Standard work for ED physicians and critical care providers is being tested.

About Virginia Mason Medical Center
Virginia Mason Medical Center, founded in 1920, is a nonprofit comprehensive regional health care system in Seattle that combines a primary and specialty care group practice of more than 440 physicians with a 336-bed acute-care hospital. Virginia Mason operates a network of clinics throughout the Puget Sound area, and Bailey-Boushay House, a skilled-nursing facility and chronic care management program for people with HIV/AIDS. The medical center is affiliated with Benaroya Research Institute at Virginia Mason, internationally recognized in autoimmune disease research. Virginia Mason is known for applying manufacturing principles to health care to improve quality and patient safety. For more information, visit Facebook/VMcares or follow @VirginiaMason on Twitter.

Related Links:
Quality and Patient Safety at Virginia Mason

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