MAR VERIFICATION BY PHARMACISTS

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Charles A. Cannon, JR. Memorial Hospital
MAR VERIFICATION BY PHARMACISTS NURSES Spring
2003
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History of Hospital and Unit

• Cannon Memorial Hospital
• 2 rural hospitals merged and built a new facility
  3 years ago
• 70 bed acute care facility in the NC mountains
• 20 bed behavioral health unit with 20 beds
• Unit is predominantly geriatric psych

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Pharmacy

• Pyxis dispensing and patient profile system
• Dairyland computer system
• Orders entered both by pharmacists and pharmacy
  technicians
• Limited hours

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Cannon Memorial Hospital Goals

• Patient Safety
• Patient Satisfaction
• Medication Process Safety

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FMEA Topic

• Medication Administration Process

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Improvement Opportunities Identified via FMEA

• Reduce problems relating to medication order
  transcription accuracy
• Pharmacist verifies MAR changes by nursing each
  day
• Pyxis Connect scanning technology improves
  legibility
• Unacceptable abbreviations list
• Improved method of daily MAR verification by
  nursing
• Timely review of medication orders by the
  pharmacist
• Improve medication administration practices
• Medications removed from unit dose package at
  bedside
• Medications not charted until administered

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Purpose

• The primary purpose of the study was to decrease
  MAR discrepancies on the Behavioral Health Unit
  by directly involving pharmacists and nursing in
  the MAR verification process.

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Statement of the Problem

• New MARs and IS system
• DFS and JCAHO surveys pending
• Air of mystery among pharmacy and nursing
• Medication errors due to MAR discrepancies
• Current system of MAR verification often did not
  reach pharmacy

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Objectives

• Improved documentation
• Increased accuracy of MAR
• Prevention of medication errors related to
  incorrect MAR
• Develop team atmosphere between pharmacy and
  nursing
• Better understanding between pharmacy and nursing
  of each others roles and challenges

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Methods

• Pharmacists go to unit to check MAR each day.
• Pharmacists pull new orders and compare them to
  current MAR.
• Pharmacists look for handwritten correction by
  nursing as triggers to MAR discrepancies.

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Methods

• MAR verification tool for nursing
• Discussed at BHU staff meetings
• Education done with nursing on tool
• Instructed to use tool every night shift
• Actual discrepancy-duplication, time, omission,
  confusing presentation on MAR due to computer
  glitch

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Challenges

• Reliance on memory nursing to complete MAR
  verification form and fax to pharmacy
• Reliance on memory of pharmacists to check
  verification form to make changes
• Length of time that elapses between MAR printing
  and the verification form reaching pharmacy
• Nursing and pharmacy difference of opinion of
  what constitutes a MAR discrepancy

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Challenges (cont.)

• Pharmacists not using tool to document their MAR
  verification
• Occasionally pharmacists unable to do MAR checks
  in person due to workload
• Nurses view that this is just one more form to
  fill out and we are busy!

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Results from Nursing Verification

• 35/53 days the MAR verification form was
  completed on Behavioral Health Unit for a
  completion rate of 60
• 123 comments were made on the MAR verification
  form by nursing.
• 30 comments were deemed by pharmacy as true MAR
  discrepancies for a rate of 24.

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Computer Glitches Discovered

• Future order will not show on MAR.
• Order with frequency less than every day cannot
  show on MAR without time showing on MAR as well-
  cannot do XXXXX on days not due.
• Hold orders do not show on MAR unless default to
  hide hold orders is inactivated.

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Interesting Uses of the Tool

• Notified pharmacy when medication was not loaded
  on Pyxis, but on patient profile.
• Informed pharmacy when one form of drug was
  preferred, such as concentrate instead of pill
  form.
• Nurses questioned substitutions they need more
  education about.
• Became a catch all communication tool between
  nursing and pharmacy.

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Suggested Changes to the Tool

• Have nurse put date and time completed.
  Difficult to determine real date sometimes due to
  night shift.
• Have patient initials on form for pharmacists
  quick access.
• Have patient account number on form for
  retrospective use.

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WORK IN PROGRESS
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Conclusions

• Pharmacists can document many of their MAR
  findings as interventions.
• Difficult to quantify pharmacist impact without
  paper documentation.
• Reinforcement with nursing staff is crucial to
  receiving forms.
• MAR administration times- nurses and pharmacists
  may have to learn to agree to disagree.
• Nursing may need education to clarify what
  discrepancies are.

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Conclusions (cont.)

• Nursing MAR verification form can easily be used
  on other units- quick and specific and nurses
  already working with the MARs.
• Difficult to do pharmacist MAR verification on
  larger units and couldnt handle more than one
  unit at a time due to workload.
• Even if only one serious error is caught a month,
  pharmacists and nurse MAR verification is worth
  doing
• The most important discovery was...

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Nurses and pharmacists can work and play well
together.