A systems approach to the problem of missing medications

Area of Science:

• Pharmacy Practice
• Healthcare Systems Engineering
• Medication Safety

Background:

• Missing medication requests pose a significant challenge in hospital pharmacy operations.
• Discrepancies between nursing medication administration records (MAR) and pharmacy profiles contribute to medication errors.
• Inefficiencies in drug-distribution subsystems can impact patient care.

Purpose of the Study:

• To evaluate the impact of a systems approach on reducing missing medication requests.
• To identify the most effective components of the intervention for improving medication availability.
• To investigate specific areas within the drug-distribution subsystem requiring further attention.

Main Methods:

• Implementation of a comprehensive systems-change intervention in a pharmacy satellite.
• Analysis of medication request data before and after the intervention.
• Comparison of outcomes between systems-change and pharmacy personnel-change phases.
• Examination of discrepancies between nursing MAR and pharmacy profiles.

Main Results:

• A 38% overall decrease in the frequency of missing medication requests was achieved.
• The systems-change phase demonstrated the most substantial impact on reducing missing medications.
• The pharmacy personnel-change phase did not significantly contribute to the overall reduction.
• A notable decrease in missing medications was observed due to resolved MAR-pharmacy profile discrepancies.

Conclusions:

• A systems approach is effective in significantly decreasing missing medication requests in a pharmacy satellite.
• Systems-level interventions are more impactful than personnel-focused changes for this specific issue.
• Addressing discrepancies between nursing MAR and pharmacy profiles is crucial for medication safety.
• Further investigation into the prn (as needed) drug-distribution subsystem is warranted.