1. The document describes medication administration errors that occurred during transitions of care for a patient receiving dialysis who was transferred between units. 2. The team created process flow maps to identify gaps, such as a lack of protocol for nursing handovers and different documentation systems between units. 3. Interventions included stocking basal insulin in the dialysis unit and developing strategies like those on the nephrology ward to improve safety during patient transfers.

1. Medication Administration Errors Associated with
Transitions of Care in Inpatients Receiving Dialysis in the
Setting of Partial Implementation of an Electronic
Medical Record and Computerized Physician Order
Entry
Erik Venos, IrfanDhalla, Catherine Yu
Department of Medicine, St. Michael’s Hospital, Toronto, ON

2. CONTEXT Her usual insulin regimen, a morning meal STAKEHOLDER IDENTIFICATION AND
insulin injection and a basal insulin ENGAGEMENT
Patient transfers between and within injection, was reinitiated
facilities are associated with negative She was transferred to the dialysis unit at Nephrology GIM
patient outcomes, with the administration 0730 for her regular dialysis GIM staff
of insulin being a problematic area Her blood sugar was normal at 0800, 17.8 Dialysis MD
GIM resident
This project aimed to identify issues with mMat 1200 and 27 mM at 1500, requiring Dialysis fellow
Endocrinology staff
transitions within the hospital on these 10 units of supplemental insulin for Renal pharmacist
GIM pharmacist
outcomes Dialysis RNs
correction GIM RNs
The eMAR did not report that the morning
SETTING meal insulin or basal insulin was Face-to-face and by email
administered
General internal medicine (GIM) ward and a CREATION OF PROCESS FLOW MAPS
nephrology ward of a tertiary care centre, INTERVENTION
which operated a dialysis unit, serving out- 1. Physician ordering to nurse
and inpatients Identifying processes that led to this error administration for patients admitted to
the GIM ward (figure 2)
Used computerized physician order entry
(CPOE) along with an electronic medication 2. Patients admitted to GIM ward requiring
Four steps were undertaken: dialysis, focusing on how insulin was
administration record (eMAR), both being given on dialysis days (figure 3)
recently implemented on inpatient units in
3. Patients admitted to nephrology ward
the hospital Identification of the relevant stakeholders requiring dialysis, focusing on how
insulinwas given on dialysis days (figure
PROBLEM/ISSUE 4)
Engagement of the relevant stakeholders
Focusedon the medication administrations MEASUREMENT AND ANALYSIS
Description and analysis patient transfers
and transitions of care between a GIM using a process flow map
ward and a dialysis unit for a patient with Identified a more complex system for Map 1
type 1 diabetes and end stage renal compared to Map 2 (Figures 2 and 3)
disease admitted to hospital Utilizing this engagement and description Found issues with insulin administration
to attempt to improve the process
What medications are given before Where does the patient eat?
the patient leaves the unit? Does the dialysis RN give insulin routinely?
What medications are deferred? Will administered medications be charted
Inpatient Patient in dialysis Inpatient returns
What handover between RNs on theeMAR or apaper chart?
leaving ward for unit for 4 hours to home ward
occurs?
dialysis
Figure 1: Considerations for designing a process flow map for hospitalized patients when leaving from and returning to their home unit from dialysis

3. Patient, receiving Medications are entered into Pharmacist acknowledges Medications are sent to floor
dialysis, is admitted to CPOE by physician order and approves where RN receives them
hospital medication
RN (via barcode) confirms that
Patient receives medication from RN as
RN acknowledges patient receipt of the patient’s medications
ordered (insulin is drawn up in syringe
medication in electronic record belong to patient
from floor supply vial)
Figure 2: A process-flow map of medication administration for patients on a GIM ward
Patient, receiving
Medications are entered into Pharmacist acknowledges Medications are sent to floor
dialysis, is admitted to
CPOE by physician order and approves where RN receives them
hospital
medication
Floor RN gives patient
Sliding scale insulin medications pre-dialysis and
Dialysis RN notes insulin
administered or charts this oneMAR
correction factor. Does
physician called about not give standard
concern (medication insulin (assumes given
Floor RN notes administration noted on Floor RN holds medication
on home unit?) scheduled during dialysis to be
medications given in paper MAR)
dialysis unit given after dialysis
Floor RN gives scheduled Performs capillary Insulin
medications post-dialysis blood glucose and Floor RN should print medi-
Pt transported to GIM
assesses whether cation list and eMAR prior to
RN to enter medications ward from dialysis
patient will eating. patient leaving ward
into eMARgiven in
Meal is eaten in dialysis
dialysis and after dialysis
Dialysis RN should
No specific protocol review patient’s Patient goes off ward for
existed as how insulin Dialysis RN looks at medications from dialysis
was noted patient medication list paper list
Medication given or
and dialysis medication
physician called about
list to determine IV
concern
meds and antibiotics to
give during dialysis Other medications
Figure 3: A process flow map of medication administration for patients on a GIM ward receiving dialysis, on a dialysis

4. Insulin Dialysis RN performs Floor RN notes medica-
Dialysis RN administers
capillary blood glucose tions given in dialysis unit
mealtime and basal insulins
and assess whether
Patient leaves ward for provided by floor RN Floor RN gives scheduled
eating
dialysis. Scheduled insulin is medications post-dialysis
Patient returns to
drawn up from floor stock RN to enter medications
Dialysis RN looks at nephrology ward
by floor RN and goes with into eMARgiven in
the patient to dialysis unit patient medication list Dialysis RN gives mealtime dialysis and after dialysis
and dialysismedication medications provided by
list to determine IV floor RN Insulin charted as
meds and antibiotics to received in dialysis unit
Other medications
give during dialysis
Figure 4: A process flow map for patients admitted to a nephrology ward receiving dialysis, on a dialysis day
Maps were distributed among the relevant 5. Basal insulins were not routinely stocked 3. The admission of patients with non-
stakeholders for feedback and information in the dialysis unit dialysis related chief complaints to the
provision nephrology ward
The practices on the nephrology ward (on 4. Flagging the charts or medical record of
GAPS IN CARE the same floor as the dialysis unit) all patients with type 1 diabetes
revealed an interesting workaround to the
system (figure 4) LESSONS LEARNED
1. The dialysis unit is an outpatient facility Floor RNs prepared CPOE-ordered insulin in
using paper medication orders and a syringes, administered in dialysis when the
paper MAR while the inpatient units use 1. The transition of care of patients
patient could be observed to be eating between units, especially the dialysis
CPOE and an electronic MAR;
outpatients supply and administer their unit, can lead to medication errors,
CONTRIBUTION TO PATIENT SAFETY AND particularly regarding insulin
own insulin and other medications QUALITY IMPROVEMENT administration
2. Patients were transferred between 2. CPOE and eMAR systems can have
unitswith no specific protocol for nursing Basal insulin to be supplied in the dialysis drawbacks that need to be noted during
handover unit, so that insulin did not have to come and after implementation
3. The patient was transferred between from the home ward if it was not supplied 3. The engagement of relevant stakeholders
units at 0730, a time when nursing by the home ward is an important strategy to gain
handover occurs Other measures were proposed for information about systems of care
consideration to improve patient safety: 4. The development of process flow maps
4. Patients were off the ward in
hemodialysis, not briefly, but for four or 1. Development of the same workaround, are helpful tools to understand complex
more hours, making the routine non- as on the nephrology ward, for other processes in the hospital
administration of medication until the units 5. Understanding these processes can lead
patient returns to the unit problematic 2. Providing dialysis RNs training on CPOE to problem identification and the
and eMAR creation of workable solutions