Hospitals frequently end up implementing suboptimal systems that actually result in a more dangerous patient safety environment. Healthcare is so inundated with poorly stratified safety guidelines and regulations that hospitals rush to initiate endless improvements in order to remain in compliance, without understanding the implementation challenges and without follow through. The results are initiatives that look great on paper at the executive level but that are completely dysfunctional at the level of patient care. Let’s look at an example.
LGR was under pressure to implement an electronic pre-admission Patient Medication List (PML) to reduce the incidence of medication error. A task force was put together to develop an IT-based process that would enable care providers seeing patients in the surgical pre-admission test center to enter the patient’s home medications into the computer; this record would then be printed as a separate sheet and placed into the patient’s paper chart behind the new PML tab for straightforward, easy access. Here’s the formal system:
1. Patient comes to the surgical pre-admission test center with their list of home medications.
2. The care provider evaluating the patient enters the medications into the new computerized PML template.
3. The PML is printed out and placed into the paper chart behind the new PML tab
4. The PML serves as an easy cross-reference during admission for any new medications added.
5. On discharge, the PML is referenced to ensure that the patient continues with their usual medications as appropriate.
Here’s what actually happened when the PML was launched (informal system). Computer entry of patient medications into the PML worked well enough in the pre-admit test center, provided that patients actually knew their detailed medication histories. Because the medications were now listed in the PML, the medication section of the history and physical form (H&P) was now simply noted with “see PML.” By the time the charts were assembled and the patients were on the floor recovering post-operatively, only 70% of patients seen in pre-admitting had copies of the PML in their chart. Further, only 25% of charts had the PML tab, resulting in the need for caregivers to search through the entire chart to find the PML, when it was present. With time, it became so frustrating to look through the chart for the PML that many caregivers stopped looking at all. They’re almost back to square one except that now there is no medication list in the 30% of the charts at all because the H&P says, “see PML.” You would think that caregivers could at least go online to look at the electronic version of the PML; however, access to the PML was restricted to a subset of users. So, while LGR is now in compliance with the PML guideline, appearing to be a leader in patient safety, here’s the suboptimal result that replaced the existing process:
1. In-chart documentation of pre-admission medications has dropped from 100% to 70%.
2. The PML process as developed works only 25% of the time! (PML in the chart & behind the PML tab).
3. There is now a double standard for documenting pre-admit medications since none of the surgical patients admitted directly or through the emergency department have a PML (not part of the roll-out).
4. Caregivers are so frustrated by the inconsistency that they largely forego looking for the PLM at all - it’s easier to ask the patients directly about their meds.
Food for thought:
1. As currently implemented at LGR, the PML has increased the potential for medication error by as much as 30% and it is now systematized with an IT interface. We frequently forget that while computer automation can improve safety, it is not the magic bullet. Computers are tools and not solutions: if the underlying process is not understood in its entirety, we will only automate what we already have, or make it worse.
2. The process is only understood if the people doing the work are involved! In addition to the IT folks we need to include caregivers doing the pre-operative assessment, the people involved in chart assembly and the caregivers taking care of patients during their admission.
3. Closing the implementation loop is critical. Too frequently, we launch an initiative and assume that the execution will follow to completion on its own as we run off to address the next guideline.
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