Louis Smith Hospital Wins 2009 Patient Quality and Safety Award

Louis Smith Memorial Hospital, an affiliate of South Georgia Medical Center, received the first place 2009 Critical Access Hospital Patient Quality & Safety Award from the Georgia Hospital Association at the Annual Patient Safety Summit held at Reynolds Plantation January 6th & 7th.

The Hospital was recognized by the Partnership for Health and Accountability (PHA) division of GHA, a statewide organization of hospitals, for its efforts in improving patient safety and elevating the quality of care. This award winning project involved the implementation of a Bar Coded Electronic Medication Administration Record (eMAR). To qualify for this award, the project had to be innovative and easily implemented in other similar hospital settings.

L to R: Richard Watson, PharmD; Yolanda Peters, L.P.N.; Tina Fountain, D.O.N.; Fay Flint, R.N.; Patricia Williams, L.P.N.; Theresa Gloster, R.N.; Neil Ginty, Administrator; Brenda Jordan, Lab Director; Sandra Robinson, Pharmacy Tech; Kristen Ley, R.N.; Glenda West, D.O.N. Villa; Farooq Basheer, M.D.; Jim Mathis, Engineering; Bill Wilson, Quality Manager; Buzz Tait, Engineering

This project involved strong support from the hospital board of directors, medical staff, administration, nursing, pharmacy staff members, SGMC information technology personnel, quality improvement personnel, pharmacy service providers, engineering, and representatives from various equipment manufacturers.

     Medication administration errors are unacceptable at any level, and "zero tolerance" for medication associated errors is indeed everyone's goal. However, given the complexity and variability of the long-established manual processes for dispensing medications, errors are inevitable. To add to the problem, medication nurses are often subjected to many distractions during each med pass as patients and family members request necessary services. Even though these requested services are integral components of the provision of quality care to the patient, they also interrupt the flow of the medication administration process - setting up the circumstances for medication errors to occur.

     Additionally, although not necessarily documented as med errors unless some untoward result occurs, those medications that should not be administered without prior lab results (such as anticoagulants and blood pressure medications), or that require follow-up after administration (like pain medications), often times are failure modes in an effort to establish a safe medication program. Using tools provided by GHA/PHA and preparing responses to their Safe Medication Use Assessments, we performed a careful analysis of the med errors that we were experiencing in our hospital. Even though we only experienced a few errors, our goal of "zero" prompted us to examine ways to eliminate all errors. Sixty-seven percent (67%) of the reported errors were attributed to "lapses in performance."  This team believed that the errors were not related to performance issues, but were attributable to poor system design.

Bar coding the medication administration process was started in October 2008. It was selected as a project after the Medication Management Team worked through the very complicated medication administration process. This process involves making sure that the patient always receives medications following the "five rights:" Right patient, Right drug, Right route, Right strength, Right time.

With this new system, a bar-code scanner is used to scan the patient's armband and then scan the medication bar code. If the patient is not supposed to be on that medication, the med-pass nurse is alerted and the medication is not given. If the medication is correct, the medication is administered and the dose is electronically recorded in the medical record.

Also, if a lab value is needed before a medication is given, or if a response to the medication is required, the eMAR system alerts the nurse and reminds them that their input is needed.

 Bill Wilson, Director of Ancillary Services said: "Our goal was to reduce medication errors to zero. We realized that this was a lofty goal, and that technology could not in itself provide an absolute resolution to our problem. However, we did realize that workload and distractions play an important role in helping to create circumstances that lead to med-pass errors. We concluded that if we could implement this system, and use technology to assist in insuring that the "five rights" were followed, significant improvement in this process could be achieved. After implementation we were able to reduce medication administration errors from 1.10 errors per one-thousand doses to 0.31 errors per one-thousand doses, medications are given on time, dose omissions are near zero, and input of lab values and follow-ups must be performed to satisfy prompts and queries from the eMAR system."

One nurse said: "This system has given me a sense of confidence when I pass meds. It makes sure that I am giving the right med to the right person, and I don't have to worry so much about making a serious mistake."

The work done at Louis Smith Hospital by the Medication Management Team has been instrumental in illustrating that this technology, used in major medical centers for a few years now, can be successfully implemented in small, rural hospitals such as ours.

   This event marks the second first place award from GHA won by the Hospital. In 2006 Louis Smith was awarded first place in this category for its implementation of a Radiology PACS/Teleradiology system.

     On January 29^th, (Georgia Patient Safety Day), a display demonstrating the work performed by this team will be on view at the State capital in Atlanta.

     The facility offers:

•  24-hour physician staffed emergency room

•   24-hour ambulance services

•   Laboratory services (Medical Technologists on-duty 24/7)

•   Radiology services:

(Routine Radiography, Multi-Slice CT Scanning, Ultrasound and Full-Time MRI)

•   Stress test, EKG, & Holter Monitors

•   Rehab (Physical Therapy, Occupational & Speech Therapy)

•   Long-term care nursing services
 

Louis Smith Memorial Hospital is owned and operated by SGMC. It is located at 852 West Thigpen Avenue in Lakeland, Georgia 31635.

Louis Smith Memorial   Hospital