A BEFORE AND AFTER STUDY OF THE IMPLEMENTATION OF BEDSIDE MEDICATION STORAGE AND PREFILLED NARCOTICS SYRINGES TO A POST ANESTHESIA CARE UNIT Eric JP Romeril B.Sc.Pharm.1, Melanie MacInnis Pharm.D.1,2, Leslie Gauthier R.N. M.Sc.1,3, Leslie Gillies R.N. M.Ed.1,3, Marianne Kampf R.N.1, James Paul M.D. FRCPC1,2 Affilia.ons. 1= Hamilton Health Sciences, 2= McMaster University, DeGroote School of Medicine, Department of Anesthesia, 3= McMaster University, School of Nursing INTRODUCTION Due to recent problems, including documented diversion of
narcotics; the front line staff asked for assistance in
redesigning medication use systems in the Post Anesthesia
Care Unit (PACU). A practice improvement (Plan-Do-StudyAct or PDSA) cycle was initiated to address the problem.
Current studies report 7% of medication administration
events are errors1 in an intensive care setting; and of all
those errors 6% will cause serious harm to patients2. This
suggests that 1 in 100 patients are harmed by medication
errors in our PACUs. The purpose of this study is to
determine the effects of solutions proposed by PACU staff
and if it will make the practice environment safer.
METHODS Intervention (at Juravinski Hospital (JH)):
1) Install Clear Medication lockboxes (with PIN)
2) Manufacture and supply prefilled narcotic syringes (PFS):
- Morphine 1mg/ml
OUTCOMES Percent of Total Opportunity for Error (%TOE)
=
rights of nursing practice, College of Nurses of Ontario (CNO)
standards or wasting requirements for narcotics. Calculated
as above to obtain percent of total opportunity for practice
deviations(%TOPD)
Patient Demographics
Hamilton General Juravinski Hospital Before, n=21 APer n=29 Before, n=15 APer n=31 ASA Mode 3 3 2,3 3 Avg Age 57.7 63.6 50 57.6 Male 62% 57% 43% 45% PCA 38.1% 31% 0.00% 3.2% Spinal 28.6% 31% 6.7% 6.5% Chronic pain 33.3% 6.9% 33.3% 22.6% - 2 sites [JH, Hamilton General Hospital (HGH= control)]
Data collection
- Trained(6h) & Standardized(2h) nursing student observers
- Timeline - Before (week 1&2), Process change at
JH (week 3), After-evaluation (week 4&5)
- Developed a standardized case report form for direct
observation, using convenience sampling
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Significantly more PCA and Spinal Blocks were observed at
HGH(p<.001; no stat. sig. difference before vs after groups)
- No significant difference: ASA class, Age, Cancer
- Less chronic pain “after” @ HGH, p=0.016
APer 62 36 Total 90 92 152 128 Medication Errors
Secondary Outcomes – Prevalence of narcotic
RESULTS Before - 80% of these events were for Narcotics
- Events were excluded (n=48, incorrect ID#s)
1) Medication Errors (%TOE)
2) Nursing practice deviations (%TOPD)
analysis) comparative study using non-randomized allocation
- Nurses = RN, trained and working at study site, caring for
patients in post anesthesia phase 1
- Excluded = nurses caring for patients with orders for PCA or
epidural pumps, or given regional anesthesia
JH HGH Primary outcomes
administration, Patient demographics, Nurse demographics
Data Analysis - Entry and analysis were blinded.
Categorical and continuous data was reported with risk
reductions with 95% confidence intervals and p values (chisquared, 2 group t-test and Bonferroni correction)
DISCUSSION Total medication administration events (MAE, n= 280).
Nursing Practice Deviations (NPD) = Non adherence to 8
(supplied as: 1mg, 2mg, 3mg)
Design - Prospective, controlled, blinded (data entry &
RESULTS CONT. Medication errors observed
_
(Medication administration events + Missed doses)
- Hydromorphone 0.2mg/mL ( supplied as: 0.2mg, 0.4mg)
RESEARCH POSTER PRESENTATION DESIGN © 2012
Before (%TOE) AKer (%TOE) Total JH 0 0 0 HGH 5 (13.8%) 3 (2.14%) 8 (4.5%) - 87.5% of medication errors involved narcotics
- Event rate was too low to calculate significance
Nursing Practice Deviations
Before AKer RRR ARR P 95% CI (%TOPD) (%TOPD) 4 3 +4.1% to JH (6.45%) (3.33%) -­‐48.33% -­‐3.12% 0.367 -­‐12.4% 22 28 -­‐ 11.6% to HGH (61.11%) (30.43%) -­‐50.20% -­‐30.68% 0.001 -­‐47.1 % (ARR = Absolute Risk Reduction, Relative Risk Reduction = RRR)
After the intervention at JH, we observed:
- None of the NPD observed were waste related
- Trends towards reduction in pain and sedation
UNEXPECTED RESULTS • 
Boxes had sharp corners resulting in minor injuries
• 
It took 7 hours/week to manufacture the PFS
• 
Dispensed to one patient, administered to another
• 
100% of JH nurses surveyed wanted to keep PFS
The study had a number of limitations that reduces
confidence in estimates of benefit. Completion of a case
report form was not consistent between observers, and the
use of forms needed to be clarified at multiple times
throughout the intervention. Expected rates (%TOE, %TOPD)
were much higher than observed at both sites. Student
discomfort in assessing staff nurses, subjective aspect of
NPD, and the Hawthorne Effect likely account for this
difference. HGH was the control site yet showed reductions
in medication errors and NPDs after the process change.
This suggests any observed improvement at JH is likely
spurious, and the method of assessment needs
improvement. More patients than expected had spinal
blocks and PCA, thus decreasing the number of observable
medication administrations. We began excluding them from
observation at week 3.
CONCLUSIONS 1)  Inconsistent control data decreases confidence in
results, definitive conclusions cannot be reached
2)  NPD related to narcotic wasting were reduced
3)  Narcotics are the most frequently administered
medication in the studied PACUs
Upon review of this data, stakeholders decided to
discontinue the PFSs, however the lockboxes remain.
SELECTED REFERENCES 1 –Hicks, R. W., Becker, S. C., Windle, P. E., & Krenzischek, D. A. (2007).
Medication errors in the PACU. Journal of perianesthesia nursing. 22(6), 413–419.
2 – Chapuis, C., Roustit, M., Bal, G., Schwebel, C., Pansu, P., David-Tchouda, S.,
Foroni, L., et al. (2010). Automated drug dispensing system reduces medication
errors in an intensive care setting. Critical care medicine, 38(12), 2275–2281
ACKNOWLEDGEMENTS Anne Marie El-Kahlout and Michelle Stevenson for tireless efforts producing and
managing the stock of pre-filled syringes during the study. Silvia Katsaros, Cathy
Mezzalira, Amanda Staples, Danielle Lloyd, Michelle Marcoux, Claudia Gogishvilli,
and Christine Body for their help with students, operationalizing the study and
coping with day-to-day issues. Lehanna Thebane and Emmy Cheng for help with
statistical elements. Toni Tidy for administrative support and advocacy. And our
nursing students: Chinyere Ariaga, Nayeema Mahzabeen, Dilruba Chowddhury,
Waheeda Salimi, Danielle Fabbro, Ruben Ozuna, Stephen Darfour, Chris Zeng,
Osahon Osawe