Reducing Patient Harm by Improving Medication Turn-Around Time at a Children's Hospital

In late 2002, we examined occurrence report data to determine how to reduce medication errors. Though delay of medications initially was not thought to be a significant error type, our data indicated otherwise. Prior years' aggregate analysis of incident reports showed 9% of medication error reports resulted from delay. Approximately 23% of errors involving medications resulting in patient harm were due to delay. Incident reports documented nursing frustration, parent dissatisfaction and patient harm.

In early 2003, we formed a team of nurses, pharmacists, pharmacy technicians and unit-coordinators. We defined and measured turn-around time (TAT) for medications supplied by the main pharmacy, not in floor stock. TAT begins from the time the physician placed the new medication order to the time the medication left the pharmacy. Observational measurements were taken through sampling during the quarter. Responses from list-serve questionnaires helped determine our goal of 85% of medications turned around in <90 minutes with a stretch goal of 95%.

Our baseline data found a mean TAT was 87 minutes with a high standard deviation, measured through sampling data. Pharmacy process flow was inefficient. Pharmacist order entry workload was unevenly distributed. Cart fill was inaccurate and required significant rework. Intravenous and oral syringe medications were made during the time when most discharge or discontinue orders were being processed resulting in wasted intravenous medications accounted for nearly $490,000 per year.

We used lean processing principles through a rapid improvement workshop split into a 3-day design workshop, followed by a 2-day implementation-planning workshop six-weeks later. We designed a new pharmacy workflow by eliminating many non-value added steps. The pharmacy model moved a large portion of the manufacturing process to evenings, eliminating a lot of rework. We created a new streamlined-order processing staffing model without added FTEs. One pharmacist on day and evening shifts sole responsibility is new-order checking and sending. Medication rooms, with a low patient to medication room-ratios, were designed to replace cluster-desk medication carts to reduce RN search time, as well as rework in the pharmacy. Our design also encompassed process flow eliminating wait times when computerized physician order entry (CPOE) came into place.

Following implementation of new pharmacy model in summer 2003, our median turn-around time was reduced from 75 minutes to 52 minutes. The following quarter, our institution implemented CPOE, and our median turn-around time was reduced to 23 minutes, a 69% improvement from baseline! Currently, 97% of medications are turned around in less than 90 minutes, up from 66% at baseline.

In the three months following implementation, there were no incident reports related to delay in medication TAT resulting in patient harm. Additionally, only 2.6% of incident reports written in this time period were due to medication TAT delay, down from 9%.

As of now, medication rooms are in place in three wings of our hospital with plans to retrofit five more wings before year-end. We continue to collect data to assure our improvements are sustained. The lean processing and rapid improvement cycle continues to be a successful change methodology within our organization.

We used this high profile project as an example of the importance of completing incident reports, and how incident reports are aggregated to generate patent safety improvements.