Description: Description of Team: Core team members included UNC Medical Center Operating Room (OR) clinical staff, clinical management, surgical support services/administration, OR pharmacists and pharmacy administration. UNC Health Care Information Services Division team members assigned to the pharmacy module of our EHR were also involved. Preparation and Planning: Team members met to review communication of medication needs, specifically for ophthalmology cases. This process involved reviewing doctor preference card (DPC) content and surgery scheduling requests (example: notated through a special needs field). Reporting capabilities were reviewed at the onset of this project which allowed the team to address a disconnect between staff documenting mixed medications and whether pharmacy was able to identify items as mixed.
Assessment: Our review indicated that medications which were being mixed or reconstituted in the OR were difficult to communicate and document. Another barrier which was noted was that even when clinical OR staff were free texting comments about mixtures into the intra op medication record, our pharmacy colleagues were unable to appreciate this as a mixture using their reporting tools. An additional barrier which was noted was whether a medication item was easily available to be added to preference cards and intra op documentation. As such, we began to review our documentation practices as well as what we communicated on DPCs and to staff regarding mixed medications. Several key medication combinations were identified and created as single line item entries. Our OR medication “builders” which allow multiple medications to be documented at once were reviewed and medications added for a more comprehensive list. Several medication items commonly used in the OR were identified and added to be easier to find as a clinical nurse and for the purposes of adding to DPCs. Implementation: Staff were educated regarding updated builders and encouraged to use the medication builders. The most common builder was added to all facility preference cards, and the ophthalmic builder was added for eye cases. Combination line item entries were added as appropriate to preference cards. Outcome: Staff are increasingly utilizing our medication builders to document their combination medication administrations. This is providing our pharmacy colleagues better reporting data to focus further endeavors supporting perioperative services. Implications for Perioperative Nursing: Revising and updating resources such as medication builders improves as accuracy of documentation. This translates into better reporting data, and a better picture of what is being mixed and when. The revised documentation process translates to an easier workflow for staff.