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Improvement in the Medication-Use Process at San Antonio State Hospital

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 ™" tool.

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

ISMP’s highest weighted characteristics included:

  • Target the system, not the workforce,
  • Does not rely on human memory & vigilance
  • Scientific evidence shows effective in reducing medication errors
  • Solved several medication-error related problems at same time
  • Prevent errors (high alert medications & great harm potential)
  • 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" priority.

In May 2001, about 32% of the characteristics identified as being low performing at SASH have been addressed.


Low Characteristics


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 results.

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.