New system improves PVHC’s medication

Posted 3/28/23

A new initiative at Powell Valley Hospital has significantly decreased the amount of errors that staff make when administering medication to patients.

At February’s meeting of the Powell …

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New system improves PVHC’s medication

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A new initiative at Powell Valley Hospital has significantly decreased the amount of errors that staff make when administering medication to patients.

At February’s meeting of the Powell Valley Healthcare board of trustees, PVHC pharmacy director Steven Hultgren updated the board on the initiative, which uses bar codes to reduce the number of times an incorrect medications is dispensed.

“There’s a lot of opportunities for error in the process,” he said. “Our goal is to reduce the opportunities for error by eliminating human error, or to catch errors when they occur.”

Errors are extremely rare, occurring less than 0.5% of the time (and many of those never reach the patient), but Hultgren wasn’t satisfied.

“We pay particular attention to how many of those errors, included in that 0.5%, actually reach a patient and how many of those errors are caught by interventions or processes created to eliminate such errors,” he said in an interview. “We are continuously looking at processes to eliminate opportunities for error and ensure patient safety.”

So Hultgren, who has been the hospital’s pharmacy director for the past 10 years, launched the program in the first quarter of 2022. Since then, the number of documented medication mistakes — which had stayed consistent for years — has dropped with each quarter and mistakes are now down 81% since the program’s start.

“The positive impact on the safety of our patients is significant, and the process implementation has been successful due to PVHC staff members buying into the process and recognizing the positive impact BCMA has on patient care,” Hultgren said.

A barcode label is attached to each bottle is specific to the medicine and the dosage. The nurse administering the medication scans the barcode to get the necessary information and to ensure it’s the right medicine and correct dosage.

“It’s viewed as the No. 1 way to eliminate errors,” Hultgren said, adding that when they began the program, a third of the medication errors they made reached the patient, and half of those were deemed high alert errors (errors big enough to potentially affect the patient’s health).

Hultgren said when he first began working on the program, a colleague from another hospital expressed doubts over his goal to get a vast majority of nurses onboard with the program.

“Compliance spiked over last year-and-a-half to over 90%,” he said. “It’s awesome to see that we’ve put out an expectation, a safety initiative, then we can take data and see the clear impact it’s had. We set a goal for 93% compliance, we’re at 92% … but we’re going to hit 93%. It’s not always convenient, but it makes a difference.”

It’s helped, Hultgren said, to have leadership bring their staffs onboard, which has led to more than nine in 10 situations with medication being done correctly by using the barcodes. Now the majority of medication bottles have barcodes, where initially it was just a minority. Hultgren said it was a “team effort” to get the program to where it is.

“It’s very evident that you’re doing some remarkable stuff,” said hospital board chair R.J. Kost.

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