MAR VERIFICATION BY PHARMACISTS & NURSES Spring 2003 Charles A. Cannon, JR. Memorial Hospital

History of Hospital and Unit Cannon Memorial Hospital 2 rural hospitals merged and built a new facility 3 years ago 70 bed acute care facility in the NC mountains 20 bed behavioral health unit with 20 beds Unit is predominantly geriatric psych

Pharmacy Pyxis dispensing and patient profile system Dairyland computer system Orders entered both by pharmacists and pharmacy technicians Limited hours

Cannon Memorial Hospital Goals Patient Safety Patient Satisfaction Medication Process Safety

FMEA Topic Medication Administration Process

Improvement Opportunities Identified via FMEA Reduce problems relating to medication order transcription accuracy  Pharmacist verifies MAR changes by nursing each day  Pyxis Connect scanning technology improves legibility  Unacceptable abbreviations list  Improved method of daily MAR verification by nursing Timely review of medication orders by the pharmacist Improve medication administration practices  Medications removed from unit dose package at bedside  Medications not charted until administered

Purpose The primary purpose of the study was to decrease MAR discrepancies on the Behavioral Health Unit by directly involving pharmacists and nursing in the MAR verification process.

Statement of the Problem New MARs and IS system DFS and JCAHO surveys pending Air of mystery among pharmacy and nursing Medication errors due to MAR discrepancies Current system of MAR verification often did not reach pharmacy

Objectives Improved documentation Increased accuracy of MAR Prevention of medication errors related to incorrect MAR Develop team atmosphere between pharmacy and nursing Better understanding between pharmacy and nursing of each others roles and challenges

Methods Pharmacists go to unit to check MAR each day. Pharmacists pull new orders and compare them to current MAR. Pharmacists look for handwritten correction by nursing as “triggers” to MAR discrepancies.

Methods MAR verification tool for nursing Discussed at BHU staff meetings Education done with nursing on tool Instructed to use tool every night shift “Actual discrepancy”-duplication, time, omission, confusing presentation on MAR due to computer glitch

Challenges Reliance on memory nursing to complete MAR verification form and fax to pharmacy Reliance on memory of pharmacists to check verification form to make changes Length of time that elapses between MAR printing and the verification form reaching pharmacy Nursing and pharmacy difference of opinion of what constitutes a MAR discrepancy

Challenges (cont.) Pharmacists not using tool to document their MAR verification Occasionally pharmacists unable to do MAR checks in person due to workload Nurses view that “this is just one more form to fill out and we are busy!”

Results from Nursing Verification 35/53 days the MAR verification form was completed on Behavioral Health Unit for a completion rate of 60% 123 comments were made on the MAR verification form by nursing. 30 comments were deemed by pharmacy as true MAR discrepancies for a rate of 24%.

Computer Glitches Discovered Future order will not show on MAR. Order with frequency less than every day cannot show on MAR without time showing on MAR as well- cannot do XXXXX on days not due. Hold orders do not show on MAR unless default to hide hold orders is inactivated.

Interesting Uses of the Tool Notified pharmacy when medication was not loaded on Pyxis, but on patient profile. Informed pharmacy when one form of drug was preferred, such as concentrate instead of pill form. Nurses questioned substitutions they need more education about. Became a “catch all” communication tool between nursing and pharmacy.

Suggested Changes to the Tool Have nurse put date and time completed. Difficult to determine real date sometimes due to night shift. Have patient initials on form for pharmacists quick access. Have patient account number on form for retrospective use.

WORK IN PROGRESS

Conclusions Pharmacists can document many of their MAR findings as interventions. Difficult to quantify pharmacist impact without paper documentation. Reinforcement with nursing staff is crucial to receiving forms. MAR administration times- nurses and pharmacists may have to learn to agree to disagree. Nursing may need education to clarify what discrepancies are.

Conclusions (cont.) Nursing MAR verification form can easily be used on other units- quick and specific and nurses already working with the MARs. Difficult to do pharmacist MAR verification on larger units and couldn’t handle more than one unit at a time due to workload. Even if only one serious error is caught a month, pharmacists and nurse MAR verification is worth doing The most important discovery was...

Nurses and pharmacists can work and play well together.