Sanctifying medication administration

In 2006, there were about 7000 deaths each year in the U.S. due to medication errors, equating to about one medication error per patient per day. The Innovation Consultancy partnered with internal Quality, National Patient Care Services, and HealthConnect teams to develop a medication administration system created and designed by frontline staff.

 

 

Exploring the root cause of medication error

Our time in hospitals observing medication administration revealed that the medication administration process is unclear, chaotic and full of interruptions.

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KP MedRite was co-designed with our nurses

KP MedRite is a medication administration system designed by frontline staff. This system features three elements that work together to keep both patients and nurses safe during the medication administration. It includes three elements:

 
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Process

The step by step workflow for RNs incorporates the 5 Rights of Medication Administration and establishes a normalized, easy to follow process. 

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Wearable Sash

Nurses wear a No Interruption Wear Sash when “passing” meds. It acts as a signal to interrupt only in case of emergency.

 

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Space Design

The Sacred Zone is a space marked on the floor where nurses pull and prepare medication. A signal to others sharing the space, the Sacred Zone allows the RN occupying it to focus without interruption.

 

 

We're proud of KP MedRite's impact.

Our two pilot sites in West Los Angeles and Hayward showed improvement after introducing our solution set

  • 50% reduction in the number of staff interruptions to the medication administration process

  • 15% faster med passes

  • 18% increase in on-time med passes

  • Increase in process reliability from 33% to 78%

In addition, there was a 105% ROI for the project in 2 years, and KP MedRite was cited as “Good Practice” by JCAHO. 

 

Harvard Business Review captured a Day in the Life story about this work.