Category: Professional Posters
Purpose: Sending patient-specific medications with a patient when the patient transfers between inpatient units presents operational and patient safety challenges. When medications are not transferred with the patient it can lead to increased costs in waste and replacement of these medications, lost time in searching for and replacing these medications, and delays in patient care. This project sought to improve the rates at which patient-specific medications are sent with a patient during transfer through implementation of a medication transfer bag process. This project was performed at an academic medical center with approximately 300 adult admission/discharge/transfer events per day.
Methods: A baseline analysis assessed the scope of medications lost during patient transfer. This analysis reviewed medication redispenses for adult inpatients who had an admission/discharge/transfer event within 24 hours preceding the redispense. Chart review confirmed whether the redispense was for a medication that was available prior to transfer or whether the redispense was unrelated to transfer.
An education initiative regarding medication transfer was performed in spring 2018 through nursing unit safety meetings. Based on feedback from these meetings, a pilot medication transfer process with nursing and pharmacy interventions was implemented from Fall 2018 to Spring 2019.
Nursing unit interventions involved the charge nurse or unit secretary bringing the transferring nurse a medication transfer bag as a visual reminder and aid for medication transfer. The medication transfer bag pilot was implemented in eight nursing units. Pharmacy interventions were implemented in the Central Pharmacy and the Critical Care and Surgery Pharmacy Division and included confirming patient location when scanning medications prior to delivery . Cartfill technicians were educated regarding patient transfer and asked to also confirm patient location on medication delivery using unit census information. Data analysis with descriptive statistics for one nursing unit was repeated following pilot implementation. Endpoints considered included number of medications lost during transfer, cost of replacing lost medications per year, types of medications most frequently lost, and delay in administration time.
Results: Baseline data analysis indicated that 132 medication doses were redispensed over a five day period for medications lost upon patient transfer. When extrapolated to a 365-day time period, the cost of replacing these medications was estimated to be greater than $100,000/year . Of the medications lost upon patient transfer, 103/132 (78%) of them were available on the nursing unit prior to patient transfer and 29/132 (22.0%) of them were still in the pharmacy cartfill delivery process when the patient transferred. The types of items most likely to be lost upon transfer were oral unit dose medications (63/132, 47.7%) and multi-dose items (21/132, 15.9%) . The average delay in administration time for medications that were replaced after being lost during patient transfer was 2 hours 53 minutes, and 4/132 (3.0%) missing medication doses were not administered at all.
Review of redispense data for a five day period in one nursing unit that had implemented the medication transfer bag process (Neurocritical Care Unit) following implementation of the medication transfer bag process indicated a 76% reduction in medications lost during patient transfer.
Conclusion: Baseline data analysis confirmed that medications lost during patient transfer had both patient care impact through delay in medication administration time and economic impact through the cost of replacing missing medications. The true cost of replacing medications lost during patient transfer is likely higher, as labor cost in replacing lost medications was not included. Following implementation of the medication transfer bag process, a reduction in missing medications was seen in one nursing unit. Future plans include analyzing the medication transfer bag process in the remaining nursing units and evaluating feasibility of expansion of the medication transfer bag process.