Involving direct-care nurses in every decision helped one hospital successfully transform its medication administration process.
As a Magnet™ organization, Sinai Hospital of Baltimore strives to consider the five Magnet components (transformational leadership; structural empowerment; exemplary professional practice; new knowledge, innovations, and improvements; and empirical outcomes) in everything it undertakes. Hardwiring these components into the change-management process ensures that direct-care nurses play a key role in projects that ultimately affect their practice areas. A recent project undertaken to improve the bedside medication administration process provides a good example.
Commitment to medication safety
In the fall of 2003, Sinai made clear its commitment to ensuring safe medication administration by automating the pharmacy department. This interdisciplinary project began with installation of robots to fill and deliver medications to patients—a change that removed much of the human-error potential of medication delivery. But we soon realized our unit-based medication delivery process, which uses centralized medication carts, would continue to lead to errors. After all, it’s easy for a nurse to grab a medication from—or for a pharmacist to deliver a medication to—the wrong drawer. It also became clear the process wouldn’t support the next step in automation—barcode reading.
With this realization, our chief nursing officer and leadership team quickly took action, committing to a complete transformation of the medication administration process. Led by one of our patient-care directors, the project was both nurse-driven and interdisciplinary. Direct-care nurses were involved in every step.
Meanwhile, partners from key areas, such as pharmacy, information services, clinical engineering, facilities maintenance, respiratory therapy, and capital improvements, joined us to provide important stakeholder input. This collaboration is the essence of transformational leadership—promotion of change, growth, and evolution within our profession.
Structural empowerment
To secure involvement of direct-care registered nurses (RNs), we held nurses’ focus groups to identify medication administration “must-haves” from the nurse’s perspective. From the resulting data, we created criteria to use when evaluating potential products to further the goal of safe medication administration. Through literature and Internet searches, we identified medication storage options, then used our criteria to narrow the list to five.
The next step: hosting prototype evaluation sessions involving direct-care RNs and partners from pharmacy, infection control, and other key areas. We contacted vendors, who brought working models of the five storage options. Attendees got a chance to work with the cabinets and test each one. Before leaving the session, each attendee completed an evaluation. Once the results were tallied, the top two choices were presented for a final evaluation session, giving direct-care RNs and others a second chance to work with and evaluate the cabinets. We made our final choice, the NetLock cabinet manufactured by Cygnus, Inc., based on the company’s ability to create a custom-designed cabinet that met the size and storage requirements articulated by our RNs.
The process we undertook exemplifies structural empowerment within a Magnet organization. By involving our RNs in evaluating products and making the final choice based on their specifications, we gave them influence over the foundations of nursing care in our hospital. This bidirectional flow of information between bedside RNs and the leadership team is fundamental to the Magnet environment.
Once we chose the cabinet, we needed to select a locking mechanism to better meet the needs of direct-care staff. As before, we asked nurses and other team members for feedback. The vendor presented several options. We ended up choosing an innovative solution called the Isonas PowerNet™ Reader, a security device that Sinai Hospital previously had used only on doors. Thinking creatively, our team worked with the vendor to apply this mechanism to our bedside process. As a result, the locks on our new medication cabinets are powered over the Ethernet, so RNs can access the cabinets via their employee badges. Nurses view this as a distinct advantage because it eliminates the need for keys and access codes. The system also allows us to track access patterns and create reports for an extra level of medication security.
Success through exemplary practice
To ensure that our RNs got a chance to fully evaluate all aspects of the new process, we chose one inpatient unit to pilot the new cabinets. This 36-bed unit started using the cabinets while installation on the other units began. During the 1-month pilot period, communication tools were created to allow nurses to communicate their questions, concerns, or necessary changes. In this way, we were able to create the new medication administration process with real-time feedback from direct-care nurses.
During the implementation phase, direct-care RN involvement became even more important. To support exemplary practice, we gave RNs significant control over decisions that directly affect their workflow. To determine cabinet placement, we rounded on each unit with the nurse manager and other RNs. As a result, we decided to situate the cabinets so that RNs could access computers at the bedside during medication administration. Our pharmacy partners recommended we carefully consider cabinet placement in isolation rooms; once the best placement was determined, the walls where cabinets would go were marked, and no changes were made without manager approval.
At the end of the pilot period, RNs in the pilot unit expressed high praise for the new cabinets. After a few minor changes requested by that unit’s staff, we were ready to go forward with implementation. Feedback from pharmacy leaders regarding the timing of our “go-live” dates was crucial, as this process would greatly affect pharmacy workflow and staffing needs. We also worked with information services staff, because bringing the new cabinets onto our system would be labor intensive.
Input from all partners indicated we should “go live” with a few units at a time. We identified the first group of four units, then brought those units’ nurse managers together with other key team members to plan for the go-live. The process included checking the functioning and placement of all cabinets, entering staff badge numbers into the system, and providing education to everyone who would use the cabinets.
The first group of units was ready for implementation in approximately 6 weeks. Response from RNs on those units was extremely positive. Each time a new group of units prepared for and starting using the cabinets, the process became smoother. The project workgroup provided updates during monthly patient-care board meetings to keep team members abreast of the progress. This created even greater excitement on units that had yet to go live. Staff on those units began to ask, “When are we going to start using the new cabinets?” By July 2010, all 450 of the new medication cabinets were in use.
Feedback from RNs on the new cabinets continues to be extremely encouraging. RNs have stated that the bedside-cabinet process has positively affected their workflow and increased their time with patients. Patients are pleased, too, by the added medication security, and state they feel better knowing that only their medications are stored in their bedside cabinet. (See Quantifying the outcomes.)
Next step: Bedside barcodes
As our bedside-medication project draws to a close, we look to the next step in improving medication safety: implementing bedside barcode reading. As with the medication cabinets project, our barcode project will use the components of the Magnet model to drive the assessment, implementation, and evaluation processes.
Selected reference
American Nurses Credentialing Center Magnet Recognition Program Application Manual, 2008 Edition. Silver Spring, MD: American Nurses Credentialing Center; 2008.
Bonnie Hartley Faust is the director of patient care at the Rubin Institute for Advanced Orthopedics, the Berman Brain and Spine Institute, and the orthopedics/trauma unit at Sinai Hospital of Baltimore, Maryland.
