CHAMPIONS OF CHANGE
Reducing Medication Errors a top priority for Marie Segars and McLeod Regional Medical Center“The first time I know I made an error I was a very young nurse. I was in my first year of practice in my first hospital setting. My patient was going to surgery that day for a typical elective procedure. I gave him the medicine and when I pushed the plunger, I thought Iíve given the wrong drug. My mistake was not critical. My patient was fine. But later I began to realize the system set me up to make an error. It isnít just about being careful. Our medication system at that time made it easy for me to make that mistake. Iíve never forgotten that lesson,” said Marie Segars, vice president, Patient Services and Chief Nurse at McLeod Regional Medical Center.
Segars' experiences as a young nurse and as a nursing executive at McLeod motivate her today. Her goal, and that of her colleagues, is zero medication errors.
“I got interested in medication safety personally and how I could use my role at the hospital to improve medication safety several years ago. Our chief pharmacist at that time didnít think the way we were reporting errors was telling us much,” said Segars. “We became very inquisitive about both physician ordering practices as well as systems issues that contributed errors of nurses and pharmacists and respiratory therapists.”
McLeod Regional Medical Center is located in Florence, South Carolina, a highly competitive health care market that serves a population of over 1 million people. There are 4000 employees working at the Medical Center, and over 300 doctors from 36 medical practices utilize its facilities. McLeod is also home to a teaching program for family medicine residents.
Aware that errors occur every day during the delivery of medications, McLeod embarked on a total redesign of its medication delivery system to make sure that the right medication is delivered to the right patient at the right time — every time.
To ensure that McCloudís redesign efforts would be effective, a wide variety of departments and disciplines were invited to participate in the effort in which Segars played a leading role. But despite the best plans for the redesign efforts, an event occurred that had a devastating impact on everyone involved.
“This child was grievously sick and the different monitoring parameters were suggesting that this child may not survive. There was a miscalculation by an inexperienced doctor writing an order for medication and a toxic dose of a drug was prescribed,” said Dr. Gerard Jebaily, Associate Director, Family Medicine Residency Program at McLeod.
The child died.
"Itís important that if a nurse sees a dose in medicine that they donít feel comfortable with, or a treatment theyíre not comfortable with that they feel like they can raise their hand and question. And in this case the nurse did the first time, but not the second time," said Segars speaking about the tragedy.
“The entire team was devastated. I donít know if people realize that doctors cry, but it was an event to weep over, and I still am very moved by it. This was a little child,” said Dr. Jebaily.
The childís death caused McLeodís medication redesign team to redouble is effort to improve safety.
Now, when a patient is admitted to the hospital, McLeodís new medication delivery system takes effect. A nurse records all medications a patient is taking at home. After new medications are prescribed, the physician enters the order directly into a computer, which provides feedback if there are any contraindications.
The medication order appears instantly in the pharmacyís computer system. The pharmacist checks the order, and then routes it to the automated dispensing cabinet on the patientís floor. Once the medication is placed in the patientís drawer in the cabinet, a nurse uses the bar code system to ensure its safe delivery.
The final step occurs during discharge, when a nurse reconciles any new prescriptions with the medications the patient is taking at home.
Transforming any element of the medication delivery system takes months of planning and coordination. At McCloud itís been a joint effort between information systems, pharmacy, nursing and the physicians, and patients as well. McLeod is determined to create a culture in which everyone feels responsible for the safety of every patient. No one feels that obligation more than Marie Segars.
“Right now I feel really good. Weíre not giving doses that are hurtful. Weíre doing the right thing. But I know out there somewhere is some new potential that I havenít discovered yet and we just canít let our guard down. Because, which patient should be victim to the error and that would be ok? And the answer is no patient,” said Segars.
Her own experiences as a young nurse and later while at McLeod Regional Medical Center have provided Segars with a unique and more holistic perspective about the causes of medication error.
“Errors occur because something is broken in the system and I find that most errors are not one golden thing that happens wrong, but thereís a series of events that makes it easy to do the wrong thing,” said Segars.
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