The Science Journal of the American Association for Respiratory Care

2012 OPEN FORUM Abstracts

“PROCESS IMPROVEMENT INITIATIVE HAS SIGNIFICANT IMPACT ON REDUCING THE NUMBER OF UNRECONCILED RESPIRATORY THERAPY MEDICATIONS IN THE ICU”

Laura G. Withers, Quan Nguyen, Clarence Finch, Kristen Price; Respiratory Care, The University of Texas MD Anderson Cancer Center, Houston, TX

BACKGROUND: Medication reconciliation has been an initiative for Joint Commission (JCAHO) and the Institute for Healthcare Improvement (IHI) for years. JCAHO defines medication reconciliation as the process of comparing a patient’s medication orders to all of the medications that the patient has been taking. This is done to avoid medication errors such as omissions. The ICU has approximately five (5) unreconciled respiratory therapy medications per day. As a quality improvement project we instituted an initiative to improve the reconciliation process. METHOD: Each unreconciled medication is considered a medication error that warrants a time consuming corrective action process to be carried out by the ICU Clinical Specialist (CS) for Respiratory Care on a daily basis. The process requires the CS to print out the “Overdue Respiratory Therapy Medication” report each morning, perform multiple chart audits for documentation review within two different systems, and electronically reconcile each medication left by the Respiratory Therapists (RT) for the past 24 hours. The CS reviewed the unresolved data with the therapist as an in-service initiative instituting an accountability process. Placing the responsibility of each to print out the overdue medication report before the end of their shift to ensure all medications have been reconciled to eliminate medication errors. To monitor the compliance of the new process the CS will print out the daily report ensuring all medications are reconciled appropriately. Evaluating the process effectiveness the CS randomly selected 100 daily medication reconciliation reports over an 11-month period pre and post implementation. We calculated the number of medications left unreconciled per day on each of the electronically generated reports. RESULTS: Old process: Average of 4.62 medications per day left unreconciled (462 meds/100 reports) New process: Average of 0.99 medications per day left unreconciled (99 meds/100 reports) Improvement: Reduced the number of unreconciled medications by 78.6% CONCLUSION: The new process improved accountability and significantly reduced the number of respiratory medication errors in the ICU by 80%. Sponsored Research - None