RCA Dramatization 2 Program Transcript FEMALE SPEAKER: The Quality Council at Downtown Medical meets regularly. On the agenda for this meeting are the recommendations made by the RCA team, after intensive study on the recent medication error trend. In attendance were Mary Crown, the Director of Quality Management, Bill Smith, the CFO, John Grant, the Director of Pharmacy, Sue Whitman, the Nurse Executive, Colton Hunter, the Director of IT, and me– I’m the Risk Manager. The QM Director called the meeting to order, then reviewed the details of the medication error that triggered the root cause analysis. FEMALE SPEAKER: The patient has been admitted to a 20-bed medical unit for treatment of acute diverticulitis. FEMALE SPEAKER: And then she read the key recommendations from the RCA team. FEMALE SPEAKER: First, they recommend we’re rearrange and clearly mark all medications with their code and packaging label. Also, that we use the tall man letters approach in marking the boxes. Second, all loading of the unit dose packaging machine must be verified by a second pharmacy employee. And a signature sheet needs to be completed. And third, that we purchase additional scanners so that there are at least three backup scanners for each unit. They said we should consider purchasing tethered scanners for the bedside computers, because they are more accurate and dependable. Are there any comments? [INTERPOSING VOICES] FEMALE SPEAKER: Sounds great. FEMALE SPEAKER: I agree with all three, but it’s going to be hard to arrange the medication label, boxes, and mark with a tall man. MALE SPEAKER: And it will take some coordination to have another pharmacy employee verify the loading of the medication packaging machine. I don’t think we have the staff to do that. I mean, we’ll try. It’s a solid recommendation. FEMALE SPEAKER: Colton, do you have something to say? MALE SPEAKER: I’m not in favor of purchasing these scanners. MALE SPEAKER: Me either. © 2016 Laureate Education, Inc. 1 RCA Dramatization 2 MALE SPEAKER: New high quality scanners cost $400 each. To provide scanners for each unit plus 3 backup scanners means we need to order 75 scanners. That’s $30,000. I don’t have that in the IT budget. MALE SPEAKER: We don’t have the money anywhere in the entire budget. Not this fiscal year. And I’m not sure we’re going to have it in the future. FEMALE SPEAKER: But patient safety is our primary concern, Bill. We need the equipment for the nursing staff to use if we want to prevent further errors. MALE SPEAKER: I understand. I just don’t know where I’m going to find the money. FEMALE SPEAKER: Well, how much money do we have to purchase new scanners? MALE SPEAKER: I could put my hands on, right now, maybe $15,000. That would buy us what– 35 scanners. FEMALE SPEAKER: What if we purchased 35 now, and give each unit new scanners for the medication carts, and keep the old ones as backup. Then maybe IT could check the backup scanners on a routine basis, just to make sure they’re working. MALE SPEAKER: I don’t have the staff to be running around checking scanners. FEMALE SPEAKER: Well, how often would you need to check the scanners, and how much time would it take? MALE SPEAKER: If we checked them once a week, they’ll probably take at least two hours each time. FEMALE SPEAKER: What if you set up a schedule so each scanner is checked weekly and a few units are checked every day? Would that help with the workload? MALE SPEAKER: It would be nice if the nurses could just do it. FEMALE SPEAKER: No offense, but it always seems that when something needs to be done, we ask the nurses to do it. They only have so much time in a day. But I’ll tell you what I’ll do. I’ll talk to the nurse managers at our next meeting. And see if they can designate two of their staff to learn how to check the scanners and who to call if they don’t work. Your staff is going to have to do the training. MALE SPEAKER: Great. © 2016 Laureate Education, Inc. 2 RCA Dramatization 2 FEMALE SPEAKER: And we’ll need some type of documentation to indicate that the trainings have taken place and that the scanners are being checked on a weekly basis. Can your IT staff develop those forms? MALE SPEAKER: Just one more thing to do to cover the nurses. FEMALE SPEAKER: You know you might consider thinking it of covering the patients, making sure they receive quality care. FEMALE SPEAKER: OK. OK. I think we’re all in agreement that IT will develop the training and documentation, and that two staff members will be trained to check the scanners. How’s that sound to everyone? FEMALE SPEAKER: Great. MALE SPEAKER: That’s good. FEMALE SPEAKER: Bill and Colton, I’d like for you to include 35 scanners for next year’s budget. MALE SPEAKER: All right. FEMALE SPEAKER: For the record, I think we need to invest in making resources available to create a healthier culture around here. I mean, you can’t keep blaming the nurses and the pharmacists for medication errors, not when we have poor functioning equipment, breaking down, causing problems. FEMALE SPEAKER: I agree, and I’ll pass your recommendation along. I’d like for us to meet again in two weeks to complete the RCA. We’ll need reports on each of the three recommendations, as well as documentation that the changes have been made before we sign the document, and send it to the CEO. It would be good if each of you could get his agreement verbally in your meetings with him in advance. Agreed? FEMALE SPEAKER: Sure. [INTERPOSING VOICES]. FEMALE SPEAKER: Great. Well, thank you so much for your time. And our meeting is adjourned for today. © 2016 Laureate Education, Inc.