Improvement in the Medication-Use Process at San Antonio State
Ann L. Richards, Pharm.D., BCPP
San Antonio State Hospital
Texas Department of Mental Health and Mental Retardation
San Antonio, Texas
In 1999 San Antonio State Hospital (SASH) implemented the
McKesson Automated Healthcare Robot-Rx . Once the new
distribution system process was fully implemented, the robot
distribution system was expanded to San Antonio State School
and Kerrville State Hospital. Other programs were started
that also effected the distributive process. In 2000, the
Institute of Safe Medication Practice sent every pharmacy
director a copy of the "Medication Safety Self Assessment
The purpose of the Medication Safety Self Assessment
tool is to heighten the awareness of distinguishing characteristics
for a safe medication system and to create a baseline of efforts
to enhance the safety of medication and evaluate efforts over
time. There are ten elements with one or more core distinguishing
characteristics and 194 representative self-assessment characteristics.
After the "tool" was completed data was to be submitted
to ISMP, who weighted and determined numerical scores and
then compared scores to similar types of hospitals. The representative
self-assessment characteristics were rated as:
A. No activity to implement
B. Discussed, but not implemented
C. Partially implemented in some or all areas
D. Fully implemented in some areas
E. Fully implemented throughout
ISMPs highest weighted characteristics included:
- Target the system, not the workforce,
- Does not rely on human memory & vigilance
- Scientific evidence shows effective in reducing medication
- Solved several medication-error related problems at same
- Prevent errors (high alert medications & great harm
- Simplify complex, error-prone processes
- Safeguard high-risk patient populations
- Makes it hard to do job wrong and easy to do it right
There were many changes in the distribution process and an
adequate evaluation of the medication use process had not
been completed. The Medication Safety Self Assessment
tool offered the facility an opportunity to evaluate the medication
use process through a multi-disciplinary approach. The completion
of the tool offered the opportunity to improve the medication
use process at SASH and to obtain "buy-in" for the
medication use process by all stakeholders.
In May 2000, the pharmacy director approached the chief executive
officer (CEO) about the opportunity to evaluate the entire
medication use process by using the "tool". The
CEO appointed a Work Group to complete the tool. The Work
Group consisted of the CEO, nursing director, QM assistant
Director, clinical pharmacist, clinical director, pharmacy
director, staff psychiatrist, and two staff nurses. The pharmacy
director acted as the facilitator in the process.
To complete the "tool" in an efficient manner,
the 194 "representative self-assessment characteristics"
were divided into three parts. Each section was then reviewed
at three separate meetings. Members of the Work Group individually
evaluated each characteristic in the section prior to the
meeting according to the letter rating scale provided from
the "tool." The Work Group then met to review each
characteristic and formed a consensus about each characteristic.
The data was then submitted to ISMP. It was going to take
some time before ISMP would be able to evaluate all of the
data due to an overwhelming number of respondents.
The Work Group therefore decided to identify items rated
low in compliance (A,B,C) characteristic. The Group assigned
a priority scale (high, medium, low) and determined a responsible
party (administration, medical staff, nursing, pharmacy) for
the low rated characteristics. The "representative self-assessment
characteristics," priority rating, responsible group,
and completion date were entered into a database. The document
was then sorted by priority and by responsible party. An Ad
Hoc Committee was formed consisting of the CEO, clinical director,
nursing director, pharmacy director, and the QM assistant
director to track the progress, and meet quarterly.
When the "tool" was completed, the Work Group identified
42 characteristics that were determined to be an "A"
rating (no activity to implement), 28 as a "B" rating
(discussed, but not implemented) and 47 as a "C"
rating (partially implemented in some or all areas). Of these
low characteristics, 52 were identified as a "high"priority,
15 as "medium" priority, and 36 as "low"
In May 2001, about 32% of the characteristics identified
as being low performing at SASH have been addressed.
28 (54%) high priority
3 (20%) medium priority
6 (17%) low priority
After data was available from ISMP, SASH compared the original
score (submitted in 2000) to the maximum possible score and
derived a percentage and then did the same comparison to reflect
the new score. Improvement was made in seven of the 10 elements
in only eight months.
The benefits for using the "tool" in evaluating
the medication distribution process allowed for a systems
approach, a team effort that was non-threatening, and a sense
of "ownership" by all. SASH was able to identify
weaknesses in the medication use process, develop a system
to improve weaknesses, and develop a mechanism to monitor
There are already plans to continue to monitor the improvement
and appoint a new work group in 2003 to complete the Medication
Safety Self Assessment Tool, compare the information
to previous data, continue to identify weaknesses, and to
continue to improve.