COMM 3501
Case Discussion Questions
Riverside Hospital’s Pharmacy Services
Below are some questions for you to discuss using the discussion board. You will discuss
within your assigned group. One of you will summarize the discussion points into about a
half to one page and will post it out into the main discussion board under the topic “Case
4 Synopses”. We will have a similar assignment for the other cases (using a different
person each time, so everyone gets a crack at being the leader). The deadline for posting
the summary is Tuesday, October 26, 11:59 p.m. (Halifax time).
After the summaries have been posted to the main board, I want everyone to have a look
at the suggestions made by the other groups and react to at least one of them, positively
or negatively. In particular, you should anticipate the reactions of the various
stakeholders to the proposed changes. This second phase of the discussion must be
completed by Tuesday, 3 December, 11:59 p.m. (Halifax time).
In Canada, hospitals such as RDMH are funded mostly by public money (that is,
federal and provincial grants). Keep this in mind as you answer questions 1 through
4 below.
Q.1
Identify the key stakeholders in medication management at Riverside District Memorial
Hospital (RDMH). What are the most significant concerns of these stakeholders?
Q.2
Identify questionable practices in RDMH’s pharmacy management.
Q.3
Why does the pharmacy follow the questionable practices you identified in Q.2? In other
words, are there reasons or mitigating factors?
Q.4
What options are there for improving the situation? What decisions would you make and
why? What are the implications of your decisions?
1
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Dr. Anne Snowdon and Hannah Standing Rasmussen wrote this case solely to provide material for class discussion. The authors do
not intend to illustrate either effective or ineffective handling of a managerial situation. The authors may have disguised certain
names and other identifying information to protect confidentiality.
This publication may not be transmitted, photocopied, digitized or otherwise reproduced in any form or by any means without the
permission of the copyright holder. Reproduction of this material is not covered under authorization by any reproduction rights
organization. To order copies or request permission to reproduce materials, contact Ivey Publishing, Ivey Business School, Western
University, London, Ontario, Canada, N6G 0N1; (t) 519.661.3208; (e) cases@ivey.ca; www.iveycases.com.
Copyright © 2011, Richard Ivey School of Business Foundation
Version: 2014-02-06
As she drove to work on a Monday morning in the spring of 2009, Barbara Jordan, vice-president of
patient services and chief nursing executive at Riverside District Memorial Hospital (RDMH), thought
about the upcoming board meeting about pharmacy services at the rural hospital. RDMH was unable to
afford a full-time pharmacist, and since it was only a 62-bed hospital, there wasn’t enough work to justify a
full-time pharmacy position. RDMH had been “making do” with short-term arrangements with a variety
of pharmacists in the region. Five different pharmacists would come to RDMH from other hospitals once a
week to supply their services. More recently, Jordan had uncovered some evidence that the quality and
safety of pharmacy services might be becoming compromised. There had been an increasing number of
medication errors resulting in adverse drug events (ADEs — events where there were injuries to patients
resulting from the use of medication 1). Jordan knew there was a need to examine the quality of service
delivery in the pharmacy department.
Three weeks earlier, an elderly patient at RDMH, Mrs. Farell, died from a reaction between her anticholesterol medicine (Lipitor) and one of the antibiotics she had been prescribed by a hospital physician
following a hip replacement operation at RDMH. The patient had been on the anti-cholesterol drug since
2008 due to cardiac problems. The surgery, performed in late January 2009, went well but while in
hospital recovering she developed a secondary bleed and an infection in her wound. In early February
2009, the physician ordered antibiotics to treat the infection. Farell’s antibiotics were changed during her
treatment throughout February and included teicoplanin and fusidic acid, flucloxacillin with fusidic acid,
and doxycycline. In late February 2009, the physician took her off the drug Lipitor as a precaution because
of the drug’s risk of reaction with antibiotics. 2 However, by this time it was too late. Farell died in early
March. The pathologist’s report found that the cause of death was rhabdomyolysis and renal failure due to
probable drug reaction between Lipitor and an antibiotic. The pathologist added that it was not possible to
say which antibiotic had the adverse reaction with Lipitor.
1
J. Lazarou, B. H. Pomeranz, and P. N. Corey, “Incidence of Adverse Drug Reactions in Hospitalized Patients,” The Journal
of the American Medical Association, 279:15, 1998, p. 1200.
2
“Lipitor,” Drugs.com, www.drugs.com/lipitor.html, accessed June 21, 2011.
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RIVERSIDE HOSPITAL’S PHARMACY SERVICES
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A final issue that concerned the board was not a death but was still a substantial problem. A patient had
been prescribed a painkiller in pill form. When he complained that he was still in pain after several doses,
the head nurse investigated. While the pills looked correct on first inspection, she noticed when she looked
closer that many of the pills in the bottle were not for pain, but were instead antibiotics that looked almost
identical to the pain medication. The nurse contacted the hospital pharmacy and the correct medication
was sent to the floor and given to the patient.
Jordan’s role in the organization was the hospital risk manager, which was over and above her role as chief
nursing executive. It was her responsibility to manage risk, investigate all adverse events (including
pharmacy-related events), and recommend solutions or changes in practice to improve the quality of care
and prevent future adverse events. Any recommendations to improve risk were made with consideration of
existing budget limitations.
Jordan had been involved in a recent survey of RDMH regarding hospital safety. This survey had revealed
widespread fear of blame related to reporting events of patient risk, and a lack of awareness of risk
management strategies. Surprised by this result, RDMH had introduced a series of initiatives to improve
patient safety. The hospital began to encourage staff to report any concerns or problems in the hospital.
Many of the staff reported problems, and potential problems, with medication management in the hospital.
For example, staff reported that:
i.
ii.
iii.
There were errors in the timing, dosage and type of medication being given to patients.
Pharmacy technicians were performing duties that would normally be the job of the pharmacist.
Medications were being contaminated (unused doses of medications that had been dispensed to the
patient floor to fill prescriptions were being returned to the pharmacy and placed back in the stock
supply).
Jordan knew these issues had to be resolved before there was another serious adverse event for a patient.
These issues raised by the staff had to be resolved, and quickly. The hospital board wanted a solution. She
needed to make a recommendation at tonight’s meeting. There were several different options for RDMH.
The question was — what should she recommend at the board meeting tonight?
HOSPITAL BACKGROUND
Riverside, Ontario
Riverside, Ontario, was a rural municipality in Southwestern Ontario. Its population was roughly 25,000
people. RDMH served Riverside, as well as the farms and villages that surrounded the municipality. The
majority of people in Riverside spoke English. However, there was a growing population of seasonal
laborers that came from Mexico and Jamaica. Additionally, Mexican Mennonite settlers had also begun to
settle outside Riverside.
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This death was not the first death at RDMH that had been brought to the attention of the board. In 2008,
there were several deaths reported due to errors in the volume of morphine given to patients. All patents
had been prescribed morphine 1 to 2 mg subcutaneously but a different form of morphine product was
available in the hospital. Several times the patients received correct volumes of morphine. However, on
the day of the death of each patient, a different amount was administered in error. A different nurse
administered the morphine at each death. Each cause of death was determined to be heart failure caused by
the administering of the wrong dose of morphine.
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The Riverside District Memorial Hospital (RDMH) was opened in 1948. It was a rural community
hospital with both inpatient beds and a large outpatient population.
RDMH considered outpatient treatment and the medical management of geriatric patients to be its
specialty, which was a strong fit with the needs of the population it served. Outpatient surgeries were the
most common type of procedure offered by RDMH. A fully staffed emergency department managed the
urgent care needs of the town, and more complex cases were referred to one of two nearby community
hospitals in a medium-sized urban centre. RDMH had been increasingly working with the two nearby
hospitals to reduce costs and improve efficiency by streamlining infrastructure and services including
information technologies, referrals to specialists, and obstetrical services.
RDMH Outpatient Population
In 2004, RDMH had 100 inpatient beds. However, due to ongoing budget cuts, by 2009 there were only
62 inpatient beds remaining. The majority of these were acute care beds since wherever possible, healthy
patients were served as outpatients.
One of RDMH’s main strengths was its outpatient surgical program, which included procedures such as
cholecystectomy (removal of gallbladder, endoscopy, bladder surgery and lumpectomy). With these
surgeries, a patient was allowed to return home on the same day that a surgical procedure was performed. 3
Outpatient services were considered by many experts as the most economical and patient-focused way to
provide health care to individuals. 4 For example, outpatient surgery often reduced the amount of
medication prescribed, and used a doctor’s time more efficiently. It was also preferred by most patients as
they could return to the comfort of their own homes to recover. 5 More than 60 per cent of elective surgery
procedures in the United States were performed as outpatient surgeries in 2005. 6 Health experts expected
that this percentage would increase to nearly 75 per cent over the next decade. 7 Although not all types of
surgeries and/or patients were suitable for outpatient surgery at RDMH, 90 per cent of all surgical cases,
regardless of suitability, were performed on an outpatient basis.
Geriatric Patients
RDMH considered the medical management of geriatric patients to be its other specialty. On any given
day in 2009, the average age of an inpatient at RDMH was 86. Most of these inpatients were admitted for
acute illnesses. For example, they were admitted for acute exacerbations of one or more chronic illnesses,
3
“Definition of Outpatient,” MedicineNet.com, April 27, 2011, www.medterms.com/script/main/art.asp?articlekey=4700,
accessed May 12, 2011.
4
L. Peng and E. J. Norris, “Outpatient Surgery,” emedicinehealth, January 11, 2006,
www.emedicinehealth.com/outpatient_surgery/article_em.htm, accessed June 21, 2011.
5
Ibid.
6
Ibid.
7
Ibid.
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According to the census, the average age of people living in Riverside was 72 years. The economy of
Riverside was based on farms and greenhouses. In 2009, Riverside had the largest number of commercial
greenhouses in North America. Historically, tobacco was an important crop in the Riverside economy.
However, this was now in fast decline. Recently, Riverside was becoming a retirement community.
Riverside had many golf clubs and beautiful waterfront parks, and had a very warm climate compared to
most of Canada.
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Geriatric patients could be challenging to treat since they most often suffered multiple co-morbidities, that
is, two or more coexisting medical conditions. As people aged, they were increasingly likely to suffer
from a compromised nutritional state, have balance and gait problems, suffer from sight and hearing loss,
have out-of-date immunizations, and have cognition problems or dementia, and were more likely to suffer
from depression. 8 As a result of experiencing one or more of these illnesses, many geriatric patients were
prescribed many different medications, resulting in a challenge referred to as “polypharmacy.”
Polypharmacy referred to the interactions of multiple medications, which, when taken together, interacted
to cause adverse effects such as fatigue, dizziness, nausea and loss of coordination. 9 The adverse effects of
polypharmacy could make it very difficult for a physician to diagnose a geriatric patient quickly and
correctly. 10 Additionally, numerous medications also caused side effects that could be very dangerous, if
not deadly, to patients. 11 For example, many geriatric patients were on the blood thinner Coumadin.
Coumadin interacted negatively with many medications, including simple aspirin (both drugs prevented
platelets from clotting), which, when ingested at the same time, caused excessive bleeding that was
difficult to control. 12
Local Health Integration Network
RDMH was a part of the South East Local Health Integration Network (SELHIN). This network was one
of 14 networks that were established in 2006 in Ontario. These networks were intended to coordinate
health care across the province and to provide effective and efficient management of the health system at
the local level. The goal of local health integration networks (LHINs) was to plan and allocate resources
more efficiently to ensure better access to health care now and in the future. One of their secondary goals
was to work with local health service providers to identify ways to reduce duplication in the health system
and to improve health services in Ontario. 13
The SELHIN serviced three rural regions in Ontario that made up more than 649,000 people. It had an
annual budget of more than $900 million.
Jordan knew, from her years of working in the region, that the population had some specific health issues
that needed to be considered whenever health services were reviewed for RDMH. Specifically, the
population of the region was older, more likely to be either overweight or obese, more likely to practice
poor lifestyle habits, and more likely to have chronic health conditions (such as diabetes, chronic heart
failure, and asthma). As a result, the population of the SELHIN had higher rates of hospitalization than the
rest of Ontario.
8
J. W. Yates, “Comorbidity Considerations in Geriatric Oncology Research,” CA: A Cancer Journal for Clinicians, 51:6,
2001, pp. 329-336.
9
S. N. Hilmer and D. Gnjidic, “The Effects of Polypharmacy in Older Adults,” Clinical Pharmacology & Therapeutics, 85:1,
2009, pp. 86-88.
10
Ibid.
11
K. E. Miller, R. G. Zylstra, and J. B. Standridge, “The Geriatric Patient: A Systematic Approach to Maintaining Health,”
American Family Physician, February 15, 2000, www.aafp.org/afp/20000215/1089.html, accessed June 21, 2011.
12
C. Bartecchi and R. W. Schrier, “The Bad (Polypharmacy) and the Ugly (cocaine, methamphetamines, marijuana, and
anabolic steroids),” Online Guide to Living Healthier and Longer, www.healthierlongerlife.org/?page_id=72, accessed June
21, 2011.
13
“About LHINs,” Ontario’s Local Health Integration Networks,
www.lhins.on.ca/aboutlhin.aspx?ekmensel=e2f22c9a_72_184_btnlink, accessed June 21, 2011.
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such as chronic obstructive pulmonary disease (COPD), diabetes, infections (e.g., pneumonia) or injury
(falls).
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Across the province, at least 50 per cent of hospitals (75 hospitals) were in deficit in 2008 and almost 70
per cent (104 hospitals) were projected to be in deficit in 2009. In 2008, there was a major round of
hospital restructurings and cuts across the province of Ontario. The LHINs were told to review services in
all hospitals to either avoid a deficit or reverse a projected deficit. With the increasing costs of hospital
services across the province, there had been some discussion at the provincial level of either amalgamating
services across the regions or amalgamating hospitals, as a way to reduce health system costs. 14 The
Riverside community had always feared it would be forced to amalgamate with one of the larger
community hospitals in the region, a 40-minute drive away from Riverside.
The LHINs were required to make cuts to eliminate any waste. The LHINs’ cuts included the closure of
emergency departments, cuts to hospital departments and beds, closure of small and rural hospitals,
privatization of support services, lay-offs and attrition, increased fees for patients and their visitors, and
other measures.
The South East Local Health Integration Network had hired consultants to review the role of the
emergency rooms in three small rural hospitals, including RDMH. Additionally, service reviews to
identify cuts were underway in other hospitals within the LHIN. Another challenge for small rural
hospitals like RDMH was the availability and retention of health professionals. Due to the small number
of beds, there were always challenges ensuring that specialist care was available when needed. For
example, there was only one obstetrician in the community, pharmacists were in short supply across the
province, and diagnostic imaging technicians were difficult to retain. Adding to this challenge was the
relatively small volume of patients at RDMH, which was not large enough to sustain full-time health
professionals in practice. This was particularly an issue in the pharmacy, which, on occasion, had no
pharmacist coverage for parts or all of busy weekends.
In 2008, both the federal and provincial governments created funding for special infrastructure projects for
Ontario hospitals. LHINs could make appeals for funding for both minor capital projects and projects for
hospitals within LHINs that would result in systems that enabled authorized health care providers to
access, manage, share and safeguard patients’ medication histories. These grants had been used in other
hospitals for upgrades to heating, ventilation and air-conditioning systems, fire alarms, and master medical
gas equipment, as well as drug information systems, laboratory information systems, and telehealth. 15
RDMH Hospital Operations
RDMH had a long history of fiscal prudence and accountability, finishing each of the previous decades
with a balanced budget. No other hospital in its region had been able to achieve a balanced budget the
previous five years.
The culture of the organization was one filled with pride about this
accomplishment. The senior team promoted this message and most of the staff saw themselves as
intimately involved in producing the balanced budget (see Exhibit 1).
Being a small community hospital, the hospital staff was composed of people who had lived and worked in
this community hospital for decades. Ninety-five per cent of the staff members lived in, or around,
Riverside. Many of the hospital staff had never worked in another hospital. They were very loyal to the
14
“Cross-Province Hospital Cuts Cause Major Lay Offs, Privatization; Threaten Local Emergency Rooms, Birthing, Hospital
Beds,” Canada’s Newswire, December 2, 2008, www.newswire.ca/en/releases/archive/December2008/02/c6197.html,
accessed June 21, 2011.
15
B. Lauckner, “Ontario Health-Based Allocation Model (HBAM) Overview,” Waterloo Wellington LHIN, March 26, 2009,
www.waterloowellingtonlhin.on.ca/uploadedFiles/HBAMOverview.pdf, accessed June 21, 2011.
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hospital and were seriously concerned with the possibility that RDMH would be closed if the government
thought it wasn’t fiscally responsible. Many members of the hospital staff took part in activities
throughout the hospital to ensure that money was not wasted. RDMH had developed a procedure for
recommendations from staff to cut waste. Once a recommendation was submitted, it needed to be
approved before staff could implement it. For example, a nurse submitted a recommendation to organize a
recycling program for juice containers. She pointed out that RDMH distributed three juice containers a
day to every inpatient and on average two to every outpatient. These containers were thrown out.
However, a friend had told her that they could be returned to the local recycling company for cash. This
recommendation was approved and the juice containers were now collected every day and redeemed once
a month. This money, roughly $5,000 a year, was placed into the general budget. There were several
approved of initiatives like this that the staff members participated in to ensure that RDMH did not waste
money. However, Jordan suspected that the RDMH staff members were participating in other activities
not officially approved of by the hospital as well.
PATIENT SAFETY
Patient safety was a major concern for all hospitals in Canada. According to the Ontario government,
“Patient safety is about managing and reducing risk to ensure that the care patients receive is as safe as
possible.” 16 This involved the prevention of adverse events (AEs). These were accidental injuries or
complications caused by one or more members of a patient’s healthcare team that resulted in death,
disability or prolonged hospital stay. An AE could be an adverse drug event, a hospital-acquired infection,
a hospital-incurred patient injury, an unplanned removal, injury or repair of organ during surgery, and
many others. 17
In 2004, Baker and Norton examined the rates of AEs in Canadian hospitals. Their published results were
considered to be a wake-up call throughout the country. In their study they found that 187,500 out of 2.5
million patients admitted annually to acute care hospitals experienced an AE. Thirty-seven per cent of all
AEs were “highly” preventable. The three most common areas for AEs in a hospital were surgery,
medication and infection. 18
AEs as ADEs
While reviewing this study for information on medication-related adverse events, Jordan noted that the
authors found that one out of nine adults would potentially be given the wrong medication or wrong
medication dosage and that 24 per cent of preventable adverse events were related to medication error.
Medication errors often resulted in adverse drug events (ADEs). 19
The authors noted that many of the hospital medication systems were prone to error because they were
manual systems that relied heavily on individuals, who could make mistakes.
16
“Patient Safety,” Ontario Ministry of Health and Long-Term Care, October 26, 2009, www.health.gov.on.ca/patient_safety,
accessed June 21, 2011.
17
Baker et al., “The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada,”
Canadian Medical Association Journal, 170:11, 2004, pp. 1678-1685.
18
Ibid.
19
“The Canadian Adverse Events Study and Medication Safety,” Institute for Safe Medication Practices Canada, July 2004,
www.ismp-canada.org/download/hnews/HNews0407.pdf, accessed June 21, 2011.
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Many healthcare workers, after reading this study, called for an investment in new systems that would
decrease medication error by taking it out of the hands of fallible humans. 20 For example, hospitals
investigated purchasing computerized physician order entry to eliminate both medication errors caused by
poor handwriting and medication errors caused by the use of confusing abbreviations used by physicians. 21
The RDMH board of directors endorsed a patient safety action plan designed to raise awareness about
patient safety and to improve the safety of patients at RDMH. This action plan was made up of six
initiatives aimed to increase patient safety.
Initiative #1 - Education and Awareness
•
•
•
Increase the education and awareness about the issues of patient safety with staff and physicians.
Increase the awareness of how medication errors affect RDMH’s patients.
Increase the awareness of patient safety concerns with visitors.
Initiative #2 - Medication Management
•
•
Introduce new safe medication management practices and processes.
Control the practices surrounding the use of high-risk medications.
Initiative #3 - Incident Management
•
Implement an information systems risk management system to track and monitor patient safety
incidents.
Initiative #4 - Patient Identifier Program
•
Introduce a patient identifier program, which ensures that all patients are properly identified before a
test or procedure is performed, or before medications are administered.
Initiative #5 - Infection Avoidance in Critical Care
•
Introduce new standards and practices to avoid hospital-acquired infections.
Initiative #6 - Hand Hygiene Campaign
•
20
21
Participate in a major hand-washing campaign in participation with the Ontario Hospital Association’s
“Just Wash Your Hands.”
Ibid.
Ibid.
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AEs and RDMH
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MEDICATION MANAGEMENT INITIATIVE
To begin, Jordan investigated all adverse events involving medication administration at RDMH.
Specifically, she needed to identify the prevalence and severity of drug errors at RDMH. In professional
practice, the “Five Rights” needed to be followed with every medication administered to ensure safe
practice.
The Five Rights
There were five important steps to follow when administering medication to a patient. Anyone giving
medication in a hospital needed to ensure that “Five Rights” were practiced every time a patient received a
medication. 22
1. The Right Patient: In this step, the person administering the medication needed to identify the patient.
It was not enough just to ask the person what their name was. Sometimes the patient was confused, or
their level of consciousness was altered due to medication or a procedure, or they were non-verbal.
The person administering the medication needed to check the patient’s arm band and verify it with the
patient’s name on the chart and the doctor’s order on the chart.
2. The Right Medication: In this step, the person administering the medication needed to double check
the medication to be administered. This was very important since some medications with similar
names might look the same.
3. Right Dose: In this step, the person administering the medication needed to ensure that the right dose
of the medication was administered. Many hospitals used generic drugs and the person administering
the medication might need to measure liquid or split tablets to ensure that the dose was correct. The
dose in the original prescription needed to be checked to be sure that the dose was accurate and to
ensure that the pharmacy dispensed the correct dose and medication.
4. Right Route: In this step, the person administering the medication needed to ensure that it was being
given using the right method. For example, if the medication was ordered as an intravenous infusion it
might hurt the patient if it was given orally. Additionally, if the medication was ordered as a deep
intramuscular injection, the person administering the medication needed to ensure that a needle of the
correct length and gauge was used, and that the medication was injected safely in the correct site.
5. Right Time: In this step, the person administering the medication needed to ensure that each
medication was given at the right time. There were several reasons for this. Some medications might
interact with one another or with food so they needed to be given at the right time to avoid these
interactions. Additionally, levels of certain medications in a patient’s bloodstream needed to be
maintained to make sure the patient got the most benefit possible from the treatment.
22
F. Federico, “The Five Rights of Medication Administration,” Institute for Healthcare Improvement, November 7, 2007,
www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/ImprovementStories/FiveRightsofMedicationAdministration.htm,
accessed June, 21, 2011.
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Jordan initially focused her attention on the safety issues in the pharmacy. Specifically, she addressed safe
medication management and planned to recommend strategies to the board to support and ensure safe
medication management practices and processes.
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When Jordan looked at a further breakdown of the errors, she noted that 108 of the errors occurred during
the administration of the doses compared to only one that occurred during physician ordering, 61 during
transcription, and 26 during dispensing and delivery. However, when Jordan raised this issue with the
nurses involved in the administration of the doses, she was reminded that it was possible that some of the
errors in administration really occurred at other times but were only found when the medication reached
the nursing unit. The incident of the wrong medication being given to the patient because the pharmacy
had made a mistake was given as an example, since this error was recorded as an administration error and
not a dispensing error.
In addition to these reported errors, Jordan knew that many errors went unreported because medication
errors were reported voluntarily by the staff members who found the errors. Historically, the reaction to an
error, throughout healthcare, had been to either hide the problem or assign blame to an individual and then
punish the individual. 23 For example, at RDMH five years earlier, a nurse accidently gave the wrong
medication to a patient. Despite evidence that the label was difficult to read, that the nurse had more
patients than the College of Nurses of Ontario deemed safe as a workload, and that the nurse had worked a
double shift (two eight-hour shifts), the only outcome was the termination of the nurse. Researchers had
found that the use of blaming and punishment, or hiding the problem, had no positive impact on patient
safety. This was because it did not identify the root causes of problems. 24 Often the cause of an ADE was
not the actions of one individual, but a combination of many poor practices. This was referred to as the
“Swiss cheese” model of error causation in the patient safety literature. In this understanding of ADE,
many poor practices existed and one day, they would all align so that a hole was created that allowed the
safeguards to be bypassed and the ADE to occur. 25 In the example of the nurse who got fired, the practice
of working long shifts back-to-back, too many patients, and the poor quality of the label on the medication
all combined together to result in an ADE.
Clearly, there were many processes involved in safe medication dispensing and administration in the
hospital setting. Jordan needed to identify and fix the different medication dispensing practices that might
cause adverse events for patients at RDMH.
In order to do this, Jordan investigated the medication management process at RDMH.
DRUG DISPENSING PROCESS AT RDMH
“In-house” Pharmacy
An “in-house” pharmacy referred to a pharmacy that operated within the hospital. It supplied all the
medication for use in the hospital. 26 Hospital pharmacists in general were responsible for the purchase,
manufacture, dispensing, quality testing and supply of all the medicines used in the hospital. Pharmacists
23
M. Grissinger, “The Five Rights: A Destination Without a Map,” Pharmacy & Therapeutics Journal, 35:10, October 2010,
p. 542, www.ncbi.nlm.nih.gov/pmc/articles/PMC2957754/pdf/ptj35_10p542.pdf, accessed June, 21, 2011.
24
Ibid.
25
Ibid.
26
“Glossary of Pharmacy-Related Terms,” U.S. Department of Health and Human Services,
www.hrsa.gov/opa/glossary.htm, accessed June, 21, 2011.
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From January 2008 to December 2008, there were 195 reported errors at RDMH. These errors included
the wrong dose being given, a dose of medication being missed, an extra dose being given or the wrong
drug being given. Of these, 16 errors were found after harm was caused. Five of these errors might have
contributed to a patient’s death.
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These pharmacists were able to provide information to the medical staff about potential side effects and
ensure that new treatments were compatible with existing medication. For example, they were expected to
provide expert advice on medications for patients with conditions such as heart failure, and kidney or liver
disease, and for pregnant or breast-feeding women for whom certain medications were contraindicated. In
addition, they monitored the effects of treatment to ensure that medication was safe and effective. One of
their main roles in the dispensary was to “professionally check” all prescriptions to ensure that the
dispensed medicines were appropriate and safe for individual patients. 28
RDMH “In-house” Pharmacy
In 2004, RDMH had an “in-house” pharmacy staffed by one full-time pharmacist and one part-time
pharmacist. The director of the pharmacy provided pharmacist services to the hospital Monday through
Friday from 8:30 a.m. to 4:30 p.m., while the part-time pharmacist provided pharmacist services Saturday
and Sunday from 8:30 a.m. to 4:30 p.m. For pharmacist services after hours, the full-time pharmacist was
on call. In addition to the pharmacists, the pharmacy had six pharmacy technicians. The technicians
worked full-time to staff the pharmacy from 8 a.m. until 9 p.m., seven days a week.
In 2008, the South East LHIN investigated the use of pharmacists in all hospitals. It found that the number
of patients in RDMH did not justify this level of pharmacy coverage. As a result, the part-time pharmacist
position was cut. The full-time pharmacist’s on-call duties were extended to cover the weekend as well.
In situations in which the pharmacist was on holiday or sick, a pharmacist from another hospital was
contracted to be on call. Six months later, the director of the pharmacy announced that she had accepted a
position in Toronto. During her exit interview, she told the hospital human resource manager that she was
unhappy with the constant on-call duties of the RDMH position. Since the departure of the full-time
pharmacist, the hospital had been unable to fill the position. As an alternative, two part-time pharmacists
were hired to cover pharmacy services Monday through Friday from 9:30 a.m. to 3:30 p.m., and were on
call on the weekends and in the evenings. Jordan noted that it was only for unusual or critical issues that a
pharmacist was now called in. When Jordan asked about this, she was told that the pharmacy technicians
tried not to call the pharmacist unless absolutely necessary because of the on-call bonus that the hospital
had to pay each time the pharmacist was called in.
Collection System
RDMH used what was known as the collection system for delivering medication to the patients. This was
an old system that was still widely used in hospital pharmacies. Jordan followed the path of a prescription
27
“The definition of clinical pharmacy,” National Electronic Library for Medicines, January 29, 2010,
www.nelm.nhs.uk/en/NeLM-Area/Evidence/Medicines-Management/References/2010---January/29/The-definition-of-clinicalpharmacy, accessed June, 21, 2011.
28
“Hospital Standards of Practice and Guidelines on Practice in Hospital Pharmacy,” The Manitoba Pharmaceutical
Association, July 2002, www.mpha.mb.ca/pdf/Standards-of-Practice-Hospital-09.pdf, accessed June, 21, 2011.
Authorized for use only by xinxin zhang in COMM 3501 at Dalhousie University from Sep 03, 2019 to Dec 06, 2019.
Use outside these parameters is a copyright violation.
often consulted with physicians and nurses on the inpatient issues. “Clinical pharmacy” was a term which
referred to the pharmacist being involved in the clinical areas so that they could be directly involved in
patient care with the health team. They would advise on a patient’s type of medication, dose and method
of delivery — such as tablet, injection, ointment and inhaler, taking into account factors including their
existing medication, their medical history, their lifestyle and their ability to understand and adhere to a
medication treatment plan. 27
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9B11D014
from the time the physician ordered it until the patient received it, in order to see if there were any areas of
concern causing ADEs.
On a Tuesday morning at 8 a.m., an admitted patient was seen by one of the hospital’s physicians. The
patient was in great pain due to chronic cancer pain. The physician wrote an order for a narcotic analgesic,
Dilaudid, in the patient’s chart. Dilaudid was a trade name for Hydromorphone, a derivative of morphine.
This drug was three to four times stronger than morphine. It acted quickly and had a lower risk of
dependency for long-term use. It had become a very popular drug in the treatment of moderate to severe
pain. 29 This order contained the name of the drug, the dosage and the frequency: “Dilaudid 3 mg p.o.,
every 4-6 hours prn.” 30 The physician then put a red tag on the patient’s chart to alert the ward clerk that
there was a medication ordered. The ward clerk transcribed the order onto the patient’s medication record
and took the patient’s chart to the registered nurse to check that it had been transcribed correctly. The
registered nurse then initialed the order and checked the patient’s medication record for other medications
ordered. The ward clerk sent a clerk down to the pharmacy with the order. The drug order was placed in a
queue. When the pharmacist got the order, she counted out enough Dilaudid pills to last for five days, put
the pills in a medication bottle, labeled it with the patient’s name, and hospital number, and placed it in the
bin to be picked up by the clerk and delivered to the patient’s floor. The bottle was then taken up to the
floor by a clerk who gave it to the registered nurse to put it safely into the medication room on the floor.
Since Dilaudid was a narcotic (a controlled drug), it was placed in the locked narcotic drug cupboard in the
medication room. The head nurse designated one registered nurse who carried the keys to the narcotics
cupboard. After the registered nurse reviewed her patient care plans and medication for her six other
patients and gave the morning medications and care, she checked the medication room and found that her
patient’s pain medication had been delivered and placed in the locked drug cupboard. The registered nurse
found the nurse with the narcotic keys to unlock the cupboard. The two nurses reviewed the patient’s
medication orders, checked the medication and patient name on the bottle to make sure it was the correct
medication and dose, and was for the correct patient, and then recorded that the narcotic had been removed
from the locked narcotic cupboard. The medication was then given to the patient. The nurse recorded that
the Dilaudid was administered, as well as the time and dose, on the patient’s medication chart. The second
registered nurse with the narcotic keys then signed to confirm that the right drug and dose had been given
to the right patient. According to the chart, the patient received his first dose of Dilaudid at 2 p.m., six
hours after admission to the hospital.
From experience, Jordan knew that there were several problems that could arise with dispensing
medication from the pharmacy and administering a drug to a patient. First, this system relied on
handwritten medication orders. She had personally experienced trying to decipher between a physician
writing “10 mg” versus “1.0 mg” in a patient’s chart. Additionally, this process was very time consuming.
In the above example, the patient waited six hours, experiencing severe pain, before receiving his pain
medication. Because nurses did not want their patients to remain in pain or to otherwise go untreated,
nurses would sometimes “borrow” medication from one patient to give to another patient if they felt the
order was taking too long. The nurse then had to remember to replace the borrowed medication. On this
floor there were 60 to 70 drugs being administered in the morning. The nurses were very busy and would
29
30
“Hydromorphone,” The Titi Tudorancea Bulletin, October 10, 2010, www.tititudorancea.com/z/hydromorphone.htm.
p.o. = orally; prn = as needed.
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Following the Medication Path
Page 12
9B11D014
often forget to replace the borrowed medication. Finally, this system was very labor intensive. 31 It was
estimated that nurses spent about 20-30 per cent of their time administering medications. 32
After Jordan performed this review, she noticed other procedures regarding medication management that
she felt raised patient safety concerns. First, if a patient was discharged and still had medication left in the
floor medication room, the nurses returned it to the pharmacy. Instead of discarding or destroying these
medications, the pharmacy poured medications back into the stock bottles to be reused. Second, Jordan
realized that a pharmacist was not available at all times when their expertise was required. The bestpractice standard was for the pharmacist to check all medication prescriptions as they were delivered by
the clerks to ensure that there would be no medication errors. The pharmacy technicians would then
dispense and double check the prescriptions before they were picked up. However, even when the
pharmacist was on duty, many medications left the pharmacy without the prescriptions being checked by
the pharmacist. This was not technically wrong, since dispensing and double checking prescriptions
without the pharmacist was within the scope of practice of the College of Pharmacists. 33 However, in
RDMH the official policy was the same as most hospital pharmacies. In this policy, pharmacy technicians
were not allowed to perform as many tasks as their College allowed them to do within their scope of
practice. This included the dispensing and double checking of prescriptions. At RDMH, this practice had
developed without a change of official policy since inadequate pharmacist coverage was the norm and
often there was no pharmacist on duty.
OPTIONS
Jordan had identified several different options that RDMH could adopt to satisfy the medication
management concerns of the hospital. These were an integrated pharmacy, a bar-code medication
administration system (BCMAS), a unit dose system, and an automated pharmacy.
Unit Dose System
The unit dose system was a medication-dispensing system. In this system, the medication doses were
individually prepared, and packaged in bubble packs for each individual patient by a machine off site.
Each individual dose was then labeled with the name of the drug, the name of the patient, and the dose and
time the medication was to be given. Instead of the pharmacy sending up a bottle with the five days’ worth
of medication, the pharmacy sent up the five days’ worth of medication in the individual bubble packs. 34
In this system, many medications arrived at the pharmacy in unit dose packages. However, there were
many medications that the pharmacy would still receive in bulk. The pharmacy staff n e e d e d t o then
31
Shack & Tulloch, “Integrated Pharmacy Automation Systems Lead to Increases in Patient Safety and Significant
Reductions in Medication Inventory Costs,” McKesson, 2008,
www.mckesson.com/static_files/McKesson.com/MPT/Documents/MAIFiles/CaseStudy_Shore_Memorial_Hospital.pdf,
accessed June 21, 2011.
32
“Productive Ward Project,” Poole Hospital NHS Foundation Trust, www.poole.nhs.uk/about_us/productive_ward.asp,
accessed June 21, 2011.
33
Z. Austin and M. H. H. Ensom, “Education of Pharmacists in Canada,” The American Journal of Pharmaceutical
Education, 72:6, December 15, 2008, pp. 1-10, www.ajpe.org/aj7206/aj7206128/aj7206128.pdf. accessed June, 21, 2011.
34
“Lesson 2: Unit Dose System,” Parts Hangar, May 5, 2008,
www.tpub.com/content/armymedical/MD0811/MD08110020.htm, accessed June 21, 2011.
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Other Practices
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9B11D014
These systems had been in place in some Canadian hospitals since the 1970s. Jordan knew that many
hospitals in the LHIN had already converted to the unit dose system. The pharmacists and nurses all
spoke of the advantages of the system, saying that they felt it reduced medication errors,
medication waste, nursing time involved in dispensing medications to patients, and inventory holding
costs. In general, they felt it increased the amount of time both pharmacists and nurses were able to spend
in direct patient care. 35
Additionally, Jordan knew that the Canadian Society of Hospital Pharmacists endorsed the unit dose
system as a best practice. All rural hospitals in Saskatoon used this system for distributing medication to
patients. 36
However, Jordan was also told that the unit dose system was more labor intensive for pharmacies.
Pharmacies often had to increase their staffing to handle individual doses instead of sending a medication
in bulk to a ward. 37
Bar-Code Medication Administration System (BCMAS)
Another option Jordan investigated was adopting a BCMAS. In a BCMAS, each drug was labeled with a
unique bar code. The nurse and the patient also had bar codes.
BCMAS Medication Path
Jordan followed the path of a prescription from the time the physician ordered it until the patient received
it, in order to see how the BCMAS worked.
After the physician wrote a prescription, it was hand delivered to the hospital’s pharmacy in the same way
as at RDMH. The pharmacist then entered the prescription into the pharmacy computer system. The
pharmacist then dispensed a unit dose of the drug. A bar code was then attached to the unit dose. This unit
dose, five days’ worth in individual bubble packs, was then taken back to the ward, in a similar method as
at RDMH.
The nurse then received the unit dose medication on the floor. She used a handheld device to scan the bar
codes on her identification badge, the patient’s wristband, and the drug. If the system could not match the
drug to be given with the order in the system, it would alert the nurse of a possible error. At that point, the
nurse would either stop the process or override the warning. The details of the administration, including
the drug, patient, time, any warnings and the nurse’s name, would be recorded in the hospital’s electronic
35
“Rosthern
Hospital
moves
to
unit-dose system,”
The
Region
Reporter,
June
25,
2010,
http://regionreporter.wordpress.com/2010/06/25/rosthern-hospital-moves-to-unit-dose-system, accessed June 21, 2011.
36
Ibid.
37
“Disadvantages,” Parts Hangar, May 5, 2008,
www.tpub.com/content/armymedical/MD0811/MD08110021.htm.
Authorized for use only by xinxin zhang in COMM 3501 at Dalhousie University from Sep 03, 2019 to Dec 06, 2019.
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break the medications into unit doses and package them in the bubble packs. Medications
available in unit dose packages usually cost slightly more per dose t h a n t h e same
medications in bulk packaging. The pre-packaged drugs would cost $0.02 per dose. Additionally,
there would be an initial cost of $200,000 and an annual cost of $30,000 for the packaging equipment to
dispense the drugs in unit doses for patients using the bulk drugs supplied to the hospital.
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9B11D014
In a study in 2008, 31 types of problems were identified with the system. For example, unreadable
medication bar codes, malfunctioning scanners, unreadable or missing patient identification wristbands,
and non-bar-coded medications resulted in nurses having to “work around” the system. These
workarounds sometimes resulted in mistakes in the administration of medications. 39 Jordan was concerned
by these mistakes, plus the issue of cost. The system required the use of the unit dose system. In addition,
the bar-coding technology and supplies would have an initial cost of $500,000 plus a 20 per cent annual
cost. 40
Automated Pharmacy
As Jordan researched more options, one that many different hospital pharmacists mentioned to her was an
automated pharmacy. This was a system that automated the unit dose packaging, storage, and dispensing
of medication into one workstation. With this system, a physician would enter his or her prescription onto
any hospital-approved digital device. This order would be received by the workstation. The system would
then automatically dispense the unit doses package. A digital order would go to the floor, notifying the
floor that a prescription was ready to be picked up. 41
Again, Jordan knew that none of the hospitals in the LHIN used this system but that many were interested
in how it could help hospitals save money and reduce ADEs. Many hospitals in the United Kingdom had
implemented automated pharmacies. National Health Service research found that these systems reduced
the dispensing errors from 16 per cent to 50 per cent, depending on the hospital. 42 Additionally, the system
increased the efficiency of the pharmacy. Before the system was introduced, the pharmacies handled 1012 prescriptions per technician per hour. 43 With the system in place, this increased to 15 prescriptions per
technician per hour. Costs for the LHIN would exceed $2,500,000 and the annual costs would be 15-25
per cent of initial costs. 44 The LHIN would be required to sign a five-year contract with any company that
they chose to use. Additionally, the system would require the use of a BCMAS.
The results were not all positive. For example, Jordan noted that not all medications could be stored in the
system. For example, some systems could not store medication that needed refrigeration. Finally, the
system sometimes “crashed,” in which case the pharmacy could not dispense medications with the
machine, and staff would have to fill prescription orders “by hand.” 45
38
N. C. Hodges, “QA Practices for Bar Coded Unit Dose Packaging Operations,” Pharmacy Purchasing & Products
Magazine, September 2006, www.pppmag.com/article_print.php?articleid=20, accessed June 21, 2011.
39
J. Sakowski, T. Leonard, S. Colburn, B. Michaelsen, T. Schiro, J. Schneider, and J. M. Newman, “Using a Bar-Coded
Medication Administration System to Prevent Medication Errors,” American Journal of Health-System Pharmacy, 62:24,
2005, pp. 2619-2625.
40
Ibid.
41
“Pillpick® Pharmacy Automation System,” Swisslog, 2009, www.swisslog.com/hcs-pharmacyautomation.pdf, accessed
June 21, 2011.
42
S. Goundrey-Smith, “Pharmacy robots in UK hospitals: the benefits and implementation issues,” The Pharmaceutical
Journal, 280, 2008, pp. 599-602, www.pharmj.com/pdf/articles/pj_20080517_pharmacyrobots.pdf, accessed June, 21, 2011.
43
Ibid.
44
This did not include the extra costs associated with the unit dose.
45
Ibid.
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medication administration record for the tracking of possible errors in the system. 38 Jordan knew that none
of the hospitals in the LHIN used this system but that many were interested in how it could help hospitals
save money and reduce ADEs.
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9B11D014
INTEGRATED PHARMACY
The final possibility explored by Jordan was an integrated pharmacy with London General Hospital
(LGH).
LGH was a tertiary acute care hospital in the South East Local Health Integration Network. It provided
advanced care in the areas of complex trauma, renal dialysis, acute mental health, cardiac care, stroke, and
neurosurgical, as well as the broad foundation of medical and surgical services required to support these
areas of specialization. It operated 505 patient beds, cared for 14,644 inpatients a year and employed 1,985
staff.
When Jordan visited LGH, she noted that it seemed to share a similar work culture and set of values with
RDMH. The pharmacies each had a similar IT system. Additionally, she knew from the different
meetings arising out of the LHIN that there was now a high level of trust between the administrative
leaders of both hospitals.
Integrated Pharmacy
An integrated pharmacy would mean that RDMH and LGH would share their pool of pharmacists. The
part-time pharmacists at RDMH would have to become employees of LGH. The pharmacy at RDMH
would be under the leadership of the director of the pharmacy at LGH. In this situation, RDMH would
have access to LGH’s pharmacists. These pharmacists together would provide services to RDMH Monday
through Friday from 8:30 a.m. to 4:30 p.m. In addition, the RDMH pharmacy would still have six
pharmacy technicians. Patient prescriptions would be reviewed remotely by computer by a pharmacist at
LGH, when there was no coverage at RDMH. RDMH would be required to cover the cost of one and a
half full-time equivalent pharmacists in its budget. It would also be required to invest in any technology
required to allow the prescriptions to be reviewed remotely. This could include a basic scanner and
dedicated workstation, or it could require handheld digital devices for physicians to digitally record their
prescriptions.
All medication at RDMH would be packaged in unit doses by the pharmacy at LGH. Usually, one hospital
pharmacy was not allowed by law to dispense for another hospital pharmacy. However, if the pharmacies
were integrated by formal contractual agreements by the hospital boards, the legal issues would be
resolved and a special outpatient license would not be needed.
When Jordan spoke to the director of the pharmacy at LGH, Jordan pointed out that there were many
processes that would have to be harmonized between RDMH and LGH. Specifically, she asked the
director to introduce the best clinical practice standards used at LGH to RDMH’s pharmacy. This would
require RDMH’s pharmacy staff to cease both its practice of returning unused patient medications to stock
bottles and the practice of filled scripts leaving the pharmacy without pharmacist review.
CONCLUSION
As she drove into the parking lot at Riverside District Memorial Hospital, Jordan thought about what she
would recommend at the board meeting. What option or options would work best for RDMH’s board,
staff and patients?
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LGH
Page 16
9B11D014
Exhibit 1
Revenue
Inpatients - Ministry of Health and Long-Term
Care and LHIN
Inpatients - other
Outpatients
Educational programs
Marketed services
Recoveries
Amortization
Investment income
Total revenue
Expenses
Salaries and benefits
Patient care supplies and services
Utilities
General
Amortization of major equipment
Total expenses
Surplus (deficiency) of revenue over
expenses
2008
309.217
2007
300.000
8.692
11.681
31.758
5.626
17.896
6.710
.074
391.654
9.287
11.533
20.236
6.648
14.314
6.388
.018
368.424
263.220
66.162
5.214
40.715
13.215
388.526
3.128
259.799
63.423
5.083
38.020
12.015
378.340
(9.916)
PHARMACY STATEMENT OF REVENUE AND EXPENSES 2007 AND 2008
(IN THOUSANDS AND $CDN)
Revenue
Recoveries
Other
Total revenue
Expenses
Purchased services
Salaries and benefits
Supplies - printed forms
Supplies - stationery
Supplies - photocopying
Med. surg. supplies - general
Med. surg. supplies - syringes
Med. surg. supplies - gloves
Med. surg. supplies - IV
Drugs - IV
Drugs - other
Gases - oxygen
Gases - oxygen service charges
Other medical gases
General supplies
Equipment maintenance
Total expenses
Source: Created by author.
2008
5,500
1,000
6,500
2007
4,676
780
5,456
30,000
512,098
405
4,100
600
395
685
125
1,000
2,395
76,000
10,000
10,500
9,272
5,600
2,631
665,806
25,000
516,000
395
3,980
495
370
642
117
968
2,100
70,000
9212
12,000
8,800
5,000
2,500
657,579
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RDMH STATEMENT OF REVENUE AND EXPENSES 2007 AND 2008
(IN MILLIONS AND $CDN)
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