ANNUAL REPORT FY2006
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Welcome
From the Department of Pharmacy Services | Inpatient
Drug Distribution Services | Clinical
Pharmacy Services
Ambulatory
Pharmacy Services | Medication
Safety | Drug
Information and Investigation Services
Research
and Education | HomeMed
Services | Computerization
and Automation
Continuous
Quality Improvement | Purchasing,
Inventory, Management, and Distribution | Business
Operations
CONTINUOUS
QUALITY IMPROVEMENT
Quality Improvement and Regulatory Compliance Committee
The
Department of Pharmacy Services Continuous Quality Improvement Program revolves
around the departmental mission for, excellence in patient care, education, and
research. The committee’s specific intent
is to ensure the continuous competency of all staff as they render their
respective assigned duties, and a full departmental compliance of practices and
processes with all the safety and regulatory rules and regulations set by the
respective agencies and professional organizations. It is composed of the two co-chairs, for
staff competency assessment, and for regulatory compliance, in addition to the
medication safety coordinator, and the manager of ambulatory care. It is supported by a full time staff coordinator
and led by a senior pharmacy manager.
Primary Activities of the Quality Improvement and Regulatory Compliance Committee
Staff Competency
- Conducted an annual educational blitz in March. Compliance with this competency testing
this past year has been at 100%.
·
Utilized M- Learning, the computerized
administration, correction, collation, and reporting this data to respective
staff members, and provided aggregate data to both the department and the
institution.
- Replaced the bacterial surveillance program for
intravenous product with the media fill testing for all designated staff
as required by USP 797 on Pharmaceutical Compounding – Sterile
Preparations.
Regulatory Activities
- Extensive
planning took place to meet JCR recommendations for compliance with the
medication management standards and the medication-related National
Patient Safety Goals (for 2006 and 2007).
- Accreditation
applications were submitted to ASHP for our specialty residencies in
Infectious Diseases, Oncology, Informatics, Critical Care, and Pediatrics. Applications were
accepted, and the accreditation site visit will be scheduled sometime next
fiscal year.
- Centers for
Medicare and Medicaid Services (CMS) made a visit to follow-up with
concerns raised during a JCAHO validation survey conducted in February
2006. A corrective action plan was submitted and awaits final approval by
CMS. Four other CMS visits in FY 2006 were related to unsubstantiated
patient complaints. Issues raised with the pharmacy were related to dating
of multi-dose medication vials, and corrective action has taken place,
including revision of our multi-dose product and vial policy.
- Site visits by
MIOSHA related to employee safety complaints in various hospital areas
have had all citations resolved.
- Conducted surveys of all new
employees of their training/orientation experience. 35 surveys were
returned in 2006, with an improved rating over 2005 noted for helpfulness
of staff (4.23 vs. 3.75), pharmacist on-the-job training (3.77 vs. 3.33)
and technician on-the-job training (3.94 vs. 3.73). The 2005 survey
consisted of five questions, and three more questions were added in 2006,
which will be benchmarked next year.
Additional Tasks:
·
Departmental
QI plan updated (annually)
·
Planning
and implementation of the patient reconciliation process compliant with the
patient safety goals continues
·
Participation
in hospital-wide surveys and audits of medication storage areas
·
Conduction
of Periodic inpatient and outpatient pharmacies surveys and audits
·
E-mail
communications to staff and management on compliance issues
·
Preparation
and dissemination of reports as requested
·
Policy
and procedures review and coordination – three policies and procedures were
revised: Multi-Dose Vials and Products (PP 158.00), Non-Formulary Drug Use (PP
121.12) and Medications at the Bedside (PP 135.00). New policies drafted and
implemented include:
o
Medication
Administration Policy implemented (UMHHC 62-02-003)
o
Compounding
Sterile Intravenous Admixtures Policy (PP 150.00) – implemented procedures in
pharmacy IV preparation areas that are compliant with USP 797, until the clean
room is constructed in the B2 pharmacy
o
Use
of Pharmacy Facilities After Hours Policy (PP 119.02)
o
340B
Purchasing Program Policy (PP 203.00)
o
Medication
Error Review Policy (PP 327.10)
o
A
Disaster and Emergency Preparedness Policy section in the pharmacy policy
website was created, which includes addition of atropine injection preparation
procedure and disease management protocols for anthrax, botulism, plague,
smallpox, and tularemia.
·
The
structure of the QI and regulatory committee was revised to add two new
operational managers/decision makers, and planning to assess outcome in the
following areas:
·
Omnicell System:
o
Rate
and reasons for overrides
o
Controlled
substances discrepancies within pharmacy
o
Expired
medication removal: implementation of the expiration date function in Omnicell. This pilot is to be implemented in August 2006,
and will be evaluated in Omnicells scheduled for
survey later this year.
·
Employee
turn over and reasons
·
Medication
errors trending and clinical alerts and follow-up as documented in PharmDoc
·
Enforcement
of inventory control measures – to reduce inventory on hand and increase turn
over
·
Chemotherapy
double checks and accuracy will continue to be measured and remains stable
·
Inspection
rate of medication storage areas in Omnicells and
outpatient clinics will continue to be measured
·
Ambulatory
pharmacy measures including waiting time.