Do Five, Save a Life

Denali Center (Fairbanks, Alaska)

CSI Summary

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CSI Presentation

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CSI Toolkit

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Added to Collection

Project Topic

Medication administration

Hospital Unit

Aspen Neighborhood (in long-term care facility)

CSI Participants

Teresa Hrubes, BSN, RN, COHN-S
Brittney Karns, RHP
Karen Miller, RHP
Sandy Plummer, RN
Adrianna Smith, RN

Project Goals/Objectives

  1. To reduce medication orders requiring clarifications 50%
  2. To reduce medication dosing administration error due to pharmacy and electronic health record (EHR) discrepancies related to transcription 50%
  3. Decrease turnaround time from medication order entry into Denali Center EHR

Project Outcomes

  1. Decreased transcription medication errors from 60 to 11
  2. This outcome resulted in an estimated annual fiscal impact of $102,000.

Project Overview

The Fairbanks Memorial Hospital pharmacy and Denali Center nursing staff struggled with medication transcription orders resulting in staff frustration for both groups as well as for providers. CMS/Medicaid medication orders require additional information because they are processed as outpatient prescriptions, and these additional elements are not familiar to the nursing staff.

Our CSI team decided to create a standardized medication order form to help ensure the nursing staff captured all necessary information obtained to fill the prescriptions. Our goals were to reduce the number of phone calls required between nursing, pharmacy and providers to clarify incomplete orders and to reduce the potential for transcript errors due to incomplete medication orders. The nursing and pharmacy CSI team members worked together to adapt a current standardized medication form with the additional requirements. We then educated the Aspen Neighborhood unit nurses and providers before rolling out our project.

The new medication order form was used consistently by the Aspen Neighborhood nurse manager, nurse admission/discharge RN and RN charge nurses. However, it was not well-received by the medical staff, since it represented an additional form to complete. Going forward, our goal is to transition the new form to Cerner EHR to centralize processes for medication ordering between the providers, pharmacy and the hospital in 2020.

Permission to Reuse Materials
The materials associated with this AACN Clinical Scene Investigator (CSI) Academy project are the property of the participating hospital noted above, not AACN. Requests to use content contained in the CSI team’s summary, presentation or toolkit should be directed to the hospital. We suggest reaching out to the hospital’s Communications, Marketing or Nursing Education department for assistance.

The AACN CSI Academy program supports change projects based on quality improvement methods. Although CSI teams seek to ensure linkage between their project and clinical/fiscal outcomes, data cannot be solely attributed to the project and are estimations of impact.