Sunny View Memorial Hospital: a day in the life of a busy hospital pharmacy medication errors, managers, and missing medications, oh my!

Wine, Jessica N. ; Khanfar, Nile M.

CASE DESCRIPTION

The primary subject matter of this case is concerning the managerial and personnel issues in a hospital pharmacy. Focus is on the implications of mismanagement leading to localized medication errors, dissatisfied employees and a global endangerment of patient wellbeing. The case also provides insight into the behind-the-scenes of a hospital pharmacy atmosphere.

Secondary subject matter includes issues of organization and cooperation of the work force that increase the problems in the hospital. The case can be used to assist in specifically improving and understanding the function of management in a regulated healthcare setting or to generally illustrate the importance of proper leadership and organization to prevent local and global issues in the workplace.

This case has a difficulty level of two to three. The case is designed to be taught in two class hour(s), requiring three hours of preparation.

CASE SYNOPSIS

Time is 11:30am. Date is October 15, 2006. Location is Sunny View Memorial Hospital Centralized Pharmacy. Phone line 1: Emergency Room needs IV morphine STAT! Phone line 2: Surgical Room 3 still needs the syringes that were ordered three hours ago!

The incessant requests and ringing of the telephone exhaust the overworked pharmacists of the small city hospital. To add to the chaos, the hospital pharmacy manager has been insisting that the pharmacists must work even harder to prevent the errors and medication problems that have been steadily increasing over the past weeks in the hospital.

In a hectic work environment without effective guidance to reach any goals to decrease these errors is leading Sunny View Memorial Hospital down a path of destruction and failure. With an inefficient dictator-like pharmacy manager placing the blame on others and not taking control, medication orders pile up and life-threatening errors are occurring in the pharmacy and putting patient's lives at risk. The over-stressed, but experienced pharmacists are too busy to use their knowledge to correct the blatant issues that are ruining the hospital's reputation.

This case, which focuses on the local and global implications of poor management in a hospital pharmacy setting provides insight into the utility of proper management techniques in the healthcare system to enhance patient safety. Real life medication errors that have occurred in a hospital are included to further stress the importance of proper management, organization, and personnel unity and cooperation that are necessary to prevent both employee dissatisfaction and patient emergencies.

Discussion of this case will allow students to understand and diagnose the local and global problems in the pharmacy workplace environment, create goals to help reduce medication errors, and develop specific solutions to these problems using management theories and techniques.

SATURDAY OCTOBER 14, 2006: PM SHIFT

Ami Triptyline, PharmD walks into her windowless concrete cubicle known as her office just as her weekend shift begins at seven o'clock in the evening. She looks onto her desk covered in stacks of papers and files. A pink "IMPORTANT" paper sits atop the rest of her day's work:

From the Desk of Sunny View Memorial Hospital's Pharmacy Manager: Memorandum

To: Hospital Pharmacists

From: Hospital Pharmacy Manager

Date: October 14, 2006

Re: Errors and More Errors

I have become disappointed with all of you once again. After attending this month's Pharmacy and Therapeutics Committee meeting, you have had more errors this month than any other month before. I told you all at our last meeting that these errors must stop. You all need to pay attention to what is going on around you. There are lives that are in danger because of your lack of care. Next month, the centralized pharmacy is expected to make less medication errors and deliver the STAT medications within the 15-minute timeframe that is our hospital's standard. Make yourselves productive, stop the 20-minute coffee breaks and make fewer mistakes. My job is on the line to get you all to work like you are supposed to work. You all did not go to pharmacy school to make mistakes and cause problems. Show the hospital you are capable.

By the way, I will also need a few of you to work overtime next week again due to lack of pharmacist coverage in the centralized pharmacy.

I will be out of town at a manager's conference. Direct all problems to my secretary. I expect to come back and hear that there have been no errors.

SUNDAY OCTOBER 15, 2006

Centralized Pharmacy in the basement of Sunny View Memorial 2:58.... 2:59.....3:00a.m....

The shift is finally over. After working eight hours in the centralized pharmacy at Sunny View Memorial Hospital, Ami Triptyline, PharmD can finally go home. She has worked (overworked) at Sunny View Memorial Hospital for ten years now: "That was one of the most stressful eight hours on a Sunday shift! The phone has not stopped ringing and the notice I received this morning from the pharmacy manager has driven me to the edge."

Her colleague Connie Dean, PharmD., agrees: "He incessantly tells us that we are making 'unacceptable errors' and 'lives are in danger', but nothing is ever done to improve our routine except make us work longer shifts! I'll see you tomorrow for your weekly fourteen-hour shift. You need some sleep."

As Ami exits the pharmacy, she notices a new pink memo from the Hospital Pharmacy Manager in her mailbox ...

10:45 a.m.

Pharmacy Manager's Office (behind an always closed door) "I cannot believe they are making more and more errors in that centralized pharmacy. Don't they ever listen to me when I talk to them? I have told them numerous times to think clearly, work harder, and make fewer errors. We are the busiest hospital in the county. They are putting lives in danger. What more can I do?"

11:30 a.m.

Centralized Pharmacy

Fax after fax, phone call after phone call... "ER needs morphine STAT, pediatrics need insulin STAT...Surgical Room 3 is still out of syringes that they asked for 3 hours ago..." The demand is overwhelming for the two clinical pharmacists on duty, Al Prazolam and Val Sartan. After six phone calls in a row, exasperated, Al complains, "This is simply too much work for two pharmacists in a busy community hospital. I haven't gotten off the phone since I got here two hours ago." (ring ... ring ...)

Val adds, "The hospital needs to change, but our Pharmacy Manager won't even meet with us to discuss progress and improvements. He only meets with us to tell us how we are not acting as clinical pharmacists and everything we do is wrong or it's the infamous pink paper in our mailboxes." (ring...ring...) "All I feel I do is answer the phone and get yelled at. I did not go to pharmacy school for four years to be a telephone operator."

After being berated over the phone by a nurse for sending up yet another incorrect medication to the ICU, Al continues the conversation, "All our Pharmacy Manager ever talks about is the obvious--there are more errors occurring in this hospital. To top it off, he is proud of how Sunny View is the busiest hospital in the county, what the..." "BOOM!"

The two overworked pharmacists' complaints are cut short as the pharmacy door slams and the Pharmacy Manager storms into the pharmacy, "Why was morphine instead of saline sent up to the Critical Care Unit...didn't you three get my last memo? Stop making errors, patient's lives are in danger ..."

Sunny View Memorial Hospital Stats:

1. 250 bed hospital

2. Equipped with Emergency Room and Outpatient facilities

3. Built in 1973

4. No renovations since 1990

5. Centralized pharmacy only (no automatic dispensing machines on any of the floors or any decentralized pharmacies

The following are confidential documents obtained from the Medical Records office at the Sunny View Memorial Hospital.

Earlier in the month: P&T Meeting, In Attendance: Hospital Pharmacy Manager, Hospital CEO, Charge Nurses and Pharmacy Staff

Meeting called to order at 15:30.

The Pharmacy and Therapeutics Committee has examined the types of medication variances that were occurring in the Sunny View Memorial Hospital Pharmacy over the past 4 weeks. Each case was examined to figure out the severity and the party at fault. Each case has been confirmed for its validity and responsible parties have been notified.

Case #234

Newborn boy given two Hepatitis B vaccines in the Neonatal Intensive Care Unit (NICU) Protocol is one dose Hepatitis B to be given as necessary. Medical records do not record the first dosage, pharmacy records indicate ordering of two dosages. Patient risk level: moderate The party at fault was between the pharmacy and charge nurse who were to have monitored vaccine distribution and administration.

Case #367

Medical Resident infuses patient IV with Potassium Chloride. Patient consequently goes Code Blue. Patient risk level: severe

The party at fault was deemed to be the medical resident and pharmacy. Pharmacy requires proper paperwork before delivery of Potassium Chloride to the respective floors.

Case #633

Complaint by charge nurse on the 5th floor that pharmacist hung up on them when they were trying to order patient medication. Patient risk level: low

Party at fault determined to be the pharmacy, disciplinary actions to be taken. All phone calls must be taken seriously no matter how busy the pharmacy is.

Case #752

Post-surgery patient was not given Heparin drip that was required after surgical procedure. Patient risk level: moderate

The party at fault was determined to be the pharmacy. Records indicate that the pharmacy was contacted 6 times to deliver the medication to the patient. Errors such as these put patients at risk.

Case #913

The wrong size IV bag was sent to the patient. Order stated 25 ml, actual bag contained 50 ml. Patient not a risk because error caught before administration. Patient risk level: low Party at fault determined to be the IV pharmacist who must double check medication orders against compounded IV bags.

The above selected cases are the unique cases that have been brought to the committee's attention over the past month. Overall, pharmacy is responsible for 55% of the medication errors, nursing is responsible for 40% of medication errors, and 5% is a combination of multiple contributory factors.

Other statistics completed by the Pharmacy and Therapeutics Committee included the time elapsed on STAT orders. It was determined that the average STAT order was delivered within 15 minutes 35% of the time. The Sunny View Hospital standard goal is to have STAT orders to the floors at least 85% of the time within the 15-minute time frame. Over the period of 24 months, the STAT order delivery percentages have been decreasing by an average of 4.3% per month. The average time of delivery was calculated to be 75 minutes.

The Hospital Pharmacy Manager will be in charge of ensuring better STAT delivery and less medication errors for the next four week time period. It is his responsibility to get the pharmacy under control. The pharmacy was determined to be the root cause of the hospital's declining statistics.

Meeting Adjourned 16:45

Jessica N. Wine, Nova Southeastern University

Nile M. Khanfar, Nova Southeastern University