Patient Safety Stories: How one hospital leveraged interdisciplinary collaboration to tackle a flawed medication management system

Nurse Leader Insider, March 23, 2017

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Below is the first in a series of letters submitted by readers who have given Patient Safety and Quality Healthcare permission to publish their story online. If you would like to submit your patient safety story to PSQH, please send it to

In June 2015, I was working with a rural, 54-bed hospital in Tennessee to optimize its pharmacy department. While all organizations face their own set of challenges when it comes to ensuring operational excellence and patient safety, one particular issue rose to the top at this facility requiring immediate attention: Like many small, rural facilities, the hospital didn’t have a 24/7 pharmacy, and relied on automated dispensing cabinets (ADC) to provide most medications on the acute care floor. Unfortunately, these machines were often inadequately stocked, resulting in a host of issues for nursing staff.

From an operations standpoint, the absence of needed medication set off a chain of events for those on site, including the need to identify the on-call pharmacist and coordinate with him or her to deliver the drug at the facility. In the meantime, nurses were unable to meet patient needs, resulting in – at best – an impaired patient experience, and – at worst – a serious threat to patient safety via delayed treatment. In addition to these difficulties, this also strained critical relationships between the nursing and pharmacy departments – an indirect consequence with a direct effect on patient care.

To tackle this issue, my team assembled an interdisciplinary task force of pharmacy and nursing staff. Fortunately, the VP of nursing, who had been navigating ongoing complaints from her team, and the VP of operations, who had a personal passion for patient safety, expressed interest in also taking part. The group set to work reviewing the medication management system together and leveraging the performance improvement tools of Lean Six Sigma methodology to enhance it. After developing a process map to uncover the potential causes of medication unavailability, the team identified 82 variations in the medication distribution process, which caused 0.34 instances of this per patient day.

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