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Hospitals team nurses and pharmacists in collaborative med administration programs that improve delivery and reduce errors

By Glen Fest
September 17, 2003


To the nurses at Children's Medical Center of Dallas, hospital pharmacists once were like "Check Engine" lights: You only thought about them when something was wrong.

"When I first came to Children's, it was so fragmented," said Terry Pickering, RN, who worked in the hospital's emergency room. "You called and talked to the pharmacists on the phone, but you never saw them. They were in a locked department and they never got out of that department."

Less than four years later, the walls have fallen. Nurses and pharmacists now work on a face-to-face and first-name basis. Pharmacists walk out of the apothecary doors to roam the floors with nurses on regular rounds, counseling patients and reviewing drug orders. Nurses at Children's, in turn, provide immediate feedback to their pharmacy counterparts on medication efficacy or unexpected patient reactions.

Pickering is stationed inside the Children's health system pharmacy, having moved from the ER a year ago to a desk job overseeing technology systems and equipment used by nurses and physicians in administering medications.

This newfound community zeal at Children's is not from an organizational feng shui exercise, but a byproduct of a deliberate integration of medical management functions at the 348-bed hospital. Administrators at Children's-like those at several hospitals across the country-have slowly removed departmental doors to team their nurses and pharmacists in collaborative medication administration programs that improve delivery and reduce medication errors.

It is a trend driven by technology, new regulations, updated accreditation standards and the push for higher-quality patient outcomes at hospitals. A panel of five nurse and pharmacy trade associations recently put forth the idea of standardizing the integrated nursing-pharmacy model at hospitals.

New partnerships

Although it may encroach on some traditional roles for nurses in dosage administration, nursing and pharmacy experts say the new approach alleviates the growing pressure on nurses working under increasingly complex medication systems and "zero tolerance" policies for medication errors.

"For modern health care systems, what we're trying to do is move to a more team-based system," said Kacey Thompson, director of patient safety for the American Society of Health-System Pharmacists. "But by and large, we practice in silos. Information doesn't move effectively from practitioner to practitioner and patient to patient when it should."

Hospitals also play the "blame game" of punishing nurses or personnel to whom an error can be traced, although not necessarily faulted, Thompson said. "[Errors are] not so much the fault of the well-intentioned people-it's the process that we've established."

Thompson and his organization were part of the nursing-pharmacy coalition that was impaneled to study and recommend methods on how integrating functions could improve patient care. (Included on the panel were nursing officials from the American Association of Colleges of Nursing, the American Nurses Association and the American Organization of Nurse Executives.)

The coalition published a white paper in the May issue of the American Journal of Health-Systems Pharmacists explaining that the traditional role of a registered nurse in bedside drug dosage is becoming fraught with complexity and a greater emphasis on error reduction and analysis. Only by creating team-based medication management systems, on which drug administration decisions would be made with evidence-based consensus, can hospitals achieve the highest levels of patient safety and therapy effectiveness, the report stated.

Hospitals today may require anywhere from 80 to 200 steps in the delivery of a single dose of medication, from order and verification to delivery and follow-up, according to the article.

Medication errors are "a pretty common problem throughout our nation's health system, and have been spotlighted during the past 10 years specifically," Thompson said.

A 1999 Institute of Medicine report "To Err is Human" first raised the public's ire about medication errors, claiming that 44,000 to 98,000 hospital deaths occur each year because of such preventable mistakes. Thompson said most hospitals, however, have been focused on reducing the problem since the early 1990s.

Shifting roles

At Lehigh Valley Hospital and Health Network in Allentown, Pa., the three-facility hospital developed an early unit-based pharmacist system in 1995 that introduced collaborative practice between nurses and pharmacists. Lehigh's Fred Pane, administrator of pharmacy services, said the pharmacists were taken out from behind the counter of satellite dispensing areas in the hospital, and began assisting nurses and physicians with drug administration and oversight from the floor. "We even participated in code blues," Pane said. "We ended up changing the job descriptions [of pharmacists] as more clinical and not as distributive."

The inclusion of pharmacists became a valuable resource to the nurses, said Lehigh Valley nursing administrator Molly Sebastian, RN, because their presence sped the delivery of medications and improved knowledge resources for nurses. "It was great to have the ability to just to talk to somebody about allergies, for instance, and what were the appropriate medication interactions to look for," Sebastian said.

Childrens Hospital Los Angeles established satellite pharmacies for the ICU and OR units a decade ago, placing pharmacists in a real-time consultation role. Nancy Blake, MN, RN, CCRN, the hospital's director of critical care services, said the integration model has become more critical in recent years with the complexity of drugs-such as chemotherapeutic and antifungal agents-that nurses dispense to their most ill patients. "Just the fact that many of the drugs have similar names, there's something new and different every month," Blake said.

The Health-Systems Pharmacists article stated that the learning curve is not a one-way street. "Pharmacists can learn from nurses as well," according to the report. "The move toward pharmaceutical care has placed pharmacists in direct proximity with nurses, patients and patients' families. Pharmacists should work to enhance their skills of caring and compassion by observing and learning from nurses."

Improved patient safety and professional enhancements for both professions is evident, but also pushing the integrated nursing-pharmacy model are the technology systems being adopted for medication management.

The Joint Commission on Accreditation of Healthcare Organizations, in its 2001 report on the nursing crisis "Health Care at the Crossroads," noted estimates of perhaps 20,000 medication orders written daily within inpatient units at urban hospitals.

Those kinds of daunting figures naturally point to the need for automation, with information systems and technology, according to JCAHO, pointing to electronic medical records, bar coding or automated drug-dispensing machines as solutions that drastically reduce nurses' workloads. The commission noted in one example how a charge nurse's medication administration time was reduced by nearly three hours per shift through automation.

The report also stated that hospitals that provide nurses with automated medication records reduce medication errors by 79 percent and save $300,000 a year.

"With human involvement, there will be the opportunity for errors, unfortunately," said Janet Harris, MSN, RN, national director of professional services for San Diego-based Pyxis Corporation Inc., which markets medication administration technology to hospitals. "The Joint Commission jumped on the bandwagon early, and said for [hospitals] to profile the patient's medication. That's very different from the way it's been in the past for us nurses."

JCAHO standards on medication management will substantially stiffen in 2004, and likely will require more automation and collaborative risk-assessment policies for attainment. Previous written standards that required undefined "safe medication prescription or ordering" procedures, for instance, soon will be determined through a checklist of six specific conditions regarding storage, administration, patient efficacy and necessity, as well as control procedures for high-risk and investigational medications.

"We're trying to help hospitals systematize their efforts," said Nancy Kupka, associate project director for the JCAHO division of standards. "I don't think these steps are new to practice, but are new to standards."

At Children's in Dallas, Pickering is helping with a system in which automation is involved in the order entry, order processing and verification systems. Nurses carry portable scanners and handheld computer devices that contain all the information needed on a particular dose, with comparative data to ensure patient records mesh with the prescription order.

"It's so automated, the nurse can look at the point-of-care device and they know if the pharmacist has their order or they know it's a new med," Pickering said.

Pickering said the machines help nurses with more than portable, readily available information. They also are reminded through the machines' "forced functions" to verify orders, identities and security checks for narcotics and other controlled substances. Pickering said 86 percent of all medications dispensed by the hospital's health-system pharmacy are scanned and automated.

Pickering took his role as a "liaison" between nursing and pharmacy after he noticed many nurses struggling with pharmacy-based technologies that had been introduced to help fill orders. That continues to be a problem at hospitals nationwide, according to one pharmaceutical expert, who says nurses are sometimes distracted from patient care roles because of tending to drug vending machines or glitches in equipment.

Tech tools

"I think nurses ought to be involved in the technical components of medication administration," said Doug Miller, a pharmacy professor at Wayne State University in Detroit. "The technical component of getting the drugs to the nursing unit in a form that is ready to administer … is what the pharmacists ought to be doing."

Miller said many hospitals, even with heavy investments in technology, have only created problems by not fully integrating nursing and pharmacy technologies. As a result, even the safety components of automation are lost.

"Nurses, instead of just going to the unit at the time the medication is due, take all the medications for all of their patients and put them in their pockets," Miller said. "That does seem to obviate the purpose of the unit-dose, med-distribution system."

Hospitals that automate the full medication management process-order entry, processing and dispensing-run into the fewest headaches, Miller said. Those that add floor-unit pharmacists gain the further advantage of having a ready source of information and consultation.

Thompson said he and other members of the nursing-pharmacy coalition have not compiled data on how many hospitals have adopted integrated models. The purpose of the original panel was a "first-step" discussion that later will include other health care professionals in the medication management discussion, as well as lower-level state organizations in nursing and pharmacy. "We want to work together on this on how we can start moving forward with a shared vision," Thompson said.

Pickering said the cooperation between nurses and health-system pharmacists at Children's in Dallas has been a successful experiment thus far. The turf battles feared with the collaborative system have not materialized, and a system of mutual respect-and identity-has emerged.

"What I tell my nurses," Pickering said, "is that the pharmacists are the experts in med administration. We always felt we were as nurses, because we were always expected to do it. Once they understood, they felt, 'Hey, this is a great thing.' "

Contact Glen Fest at glenf@nurseweek.com