Using an integrated information system to reduce interruptions and the number of non-relevant contacts in the inpatient pharmacy at tertiary hospital

Effect of improvement measures in reducing interruptions in a Japanese hospital pharmacy using a synthetic approach based on resilience engineering and systems thinking

BACKGROUND

Workflow interruptions in pharmacies contribute to dispensing errors, a high-priority issue in patient safety, but have rarely been studied from a systemic perspective partly because of the limitations of the conventional reductionistic approach. This study aims to identify a mechanism for the occurrence of interruptions in a hospital pharmacy and find interventional points using a synthetic approach based on resilience engineering and systems thinking, and assess implemented measures for reducing them.

METHODS

At a Japanese university hospital, we gathered information about performance adjustments of pharmacists in the inpatient medication dispensing unit for oral and topical medicines (IMDU-OT) and nurses in the inpatient wards (IPWs) in the medication dispensing and delivery process. Data about the workload and workforce of pharmacists were collected from hospital information systems. Telephone inquiries and counter services in the IMDU-OT, the primary sources of interruptions to pharmacists' work, were documented. The feedback structure between the IMDU-OT and the IPWs was analyzed using a causal loop diagram to identify interventional points. The numbers of telephone calls and counter services were measured cross-sectionally before (February 2017) and four months after implementing measures (July 2020).

RESULTS

This study found that interruptions are a systemic problem emerging from the adaptive behavior of pharmacists and nurses to their work constraints, such as short staffing of pharmacists, which limited the frequency of medication deliveries to IPWs, and lack of information about the medication dispensing status for nurses. Measures for mitigating cross-system performance adjustments-a medication dispensing tracking system for nurses, request-based extra medication delivery, and pass boxes for earlier pick-up of medicines-were introduced. Following their implementation, the daily median number of telephone calls and counter services was significantly reduced (43 to 18 and 55 to 15, respectively), resulting in a 60% reduction in the total number of interruptions.

CONCLUSION

This study found interruptions in the hospital pharmacy as a systemic problem that can be reduced by mitigating difficulties being compensated for by clinicians' cross-system performance adjustments. Our findings suggest that a synthetic approach can be effective for solving complex problems and have implications for methodological guidance for Safety-II in practice.

Interrupções no trabalho da enfermagem como fator de risco para erros de medicação

Objetivo: verificar a associação entre as interrupções e os erros de medicação nas doses preparadas e administradas por profissionais de enfermagem das unidades de internação de clínica médica de dois hospitais públicos localizados no Distrito Federal, Brasil. Método: estudo exploratório, de delineamento transversal e caráter quantitativo realizado em dois hospitais públicos no Distrito Federal, Brasil. A amostra foi de conveniência, sendo 8 profissionais do Hospital 1 e 18 profissionais do Hospital 2. Os dados foram coletados a partir de observação direta e aplicação de questionário e instrumento para identificação dos fatores de risco para erros de medicação. Foram considerados significativos os resultados com valores de p < 0,05 e o índice de confiança estabelecido foi de 95 %.Resultados: em ambos os hospitais verificou-se um perfil majoritariamente de técnicos de enfermagem (H1 = 100 %; H2 = 94,4 %), do sexo feminino (H1 = 75,0 %; H2 = 88,1 %), com idade superior aos 30 anos (H1 = 75,0 %; H2 = 61,0 %). Foram observadas 899 doses no Hospital 1 e Hospital 2, que resultaram em 921 e 648 erros respectivamente, dos quais 464 (53,6 %) no Hospital 1 e 118 (24,4 %) no Hospital 2 estiveram diretamente relacionados à presença de interrupções no trabalho. Cada dose observada sofreu aproximadamente 1,7 erro e percebeu-se uma frequência de aproximadamente 26 (H1) e 16,2 (H2) erros por hora. Conclusões: verifica-se uma forte associação entre as interrupções no trabalho da equipe de enfermagem e os erros de medicação nas unidades de internação estudadas, caracterizando as interrupções como importante fator de risco.