Improving Medication Safety in the Assisted Living Setting
1
How would you describe your Action Learning Project and the difference you hope it will make to advance your organization ’ s mission ( or the field ) and benefit the individuals you serve ?
Reducing medication errors is one of our current quality indicators / goals at our assisted living program . My Action Learning Project is to implement the pouch packaged medication system , moving away from a primarily blister pack system . The pouch system uses a more precise , automated dispensing system and packaging to improve medication safety . A “ pouch ” can have up to three medications co-mingled together . Each pouch contains full identifying information for the resident and for each medication that it contains . This includes brand and generic name , dose and prescription number with full instructions for each medication . It also includes medication identifying information ; ie : “ oval white or round red ”. As the pouch system is more time efficient we hope to experience fewer medication errors including late medication / wrong time errors creating a safer environment for the residents . A more efficient pass also means fewer time restrictions on the residents waiting for their medications to be delivered , allowing for more time for engagement in activities or with other residents . In addition to improving medication safety , the pouch system is more time efficient for the staff , reducing stress thus contributing to a more enjoyable work environment .
2
How have the relationships you ’ ve developed as part of your project ( with mentors , partners , stakeholders , etc .) influenced this direction and you as a leader ?
My administrator has been a great mentor to me in getting this project off the ground . We are currently in the planning phase with re-writing policy and procedures for submission to the department of health ( DOH ) for approval . Collaborating with the director of our vendor pharmacy and getting his input for policy changes , staff training and implementation time lines has been vital to the project . Working with my administrator and the pharmacy has strengthened our working relationship while assisting me with the different components of the project to “ put it all together ”. I also hope to develop a closer relationship with the DOH as I will be the main presenter of this change via telephone prior to sending in the written proposal . The medication staff have been regularly updated on our progress hoping to develop increased trust , buy into the project and exchange of ideas as they see my commitment to improve the process .
3
What have been important turning points for you , in your own learning , as you ’ ve engaged with the action learning process ( you might consider a surprise , insight , setback , or challenge )?
This Action Learning Project has given me insight into the complexity of a large project and all of the components and people that go into a project . Each component ; policy and procedure , pharmacy , staff education and even just the physical component of ensuring we have enough med cart space , involves collaboration and good communication with each person involved for the project to be successful . With the complexity and number of components of the project , after discussing each component with my administrator and taking each component one at a time , the project became manageable . With the cooperation and support from our vendor pharmacy , I realized that help and support is only a phone call / email away and it is alright to reach out for this support . As we are still in the planning stages , I anticipate challenges to complete the project but I am looking forward to working through each challenge to full implementation of this project .
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Rae Ann Crandall Director of Clinical Services Hultquist Place-Assisted Living Program
How do you hope your project might unfold in the months and years ahead and what impact do you hope it will have on the field at large ?
We anticipate that this project will not be rolled out until July of 2017 but when it does my goal is that we will see a reduction in medication errors and improvement in our quality indicator / goal for medication safety . Once implemented we will be re-evaluating and monitoring medication errors to measure the impact of this system . We will continue to make changes and re-evaluations to reach our goal . I hope this system , with its improved time efficiency , will give our residents more freedom with their time . I hope that our staff will have less stress and therefore , a more enjoyable work environment . I also hope this system may become a model for other adult homes and assisted living facilities .
( Continued on page 7 ) LeadingAge New York 6