While most patients’ medications are supplied by the hospital, certain clinical trials require patients to bring medications procured from outside pharmacies. Previously, there was no established protocol for storing these medications, resulting in one patient’s medications being misplaced during a room transfer.
This led to a disruption in the clinical trial protocol and patient distress. The patient and family expressed their concern over the lack of hospital safeguards to prevent the loss of patient-supplied medications.
As part of a service recovery effort, the care team, and later the Patient and Family Relations Department, met with the patient and family, apologizing for the mistake and listening to their concerns. The principal investigator spoke with the patient and family, as well, apologizing for the error over the phone and connecting with local and hospital pharmacies to obtain the medication.
Nursing leaders and the Department of Quality and Safety worked together to investigate the event and create a workgroup to improve the storage of patient-supplied medications.
Led by Caitlin Guerrero, MSN, RN, OCN, CNL, nursing program director for Inpatient Oncology Research, the workgroup championed the following changes across all Oncology units:
- Designating an Omnicell drawer for patient-supplied medication
- Creating an Epic banner to alert caregivers at discharge that the patient has medications that were secured during admission
- Developing a tip sheet outlining the documentation process in Epic for safe storage and return of medications
- Updating the hospital-wide policy for patient-supplied medication administration and improving the process for documenting medications in the EHR
- Educating staff on the units
Since these changes, all Oncology units have been able to safely store, administer and return patient-supplied medications at discharge, with no further losses documented.
After the Oncology pilot, this process was implemented across all inpatient units.
Why It’s Magnet
Magnet designation requires an example of a nurse-driven initiative based on patient feedback that was received as a result of a service recovery effort as part of the Exemplary Professional Practice (EP17) component of the Magnet model. This is one of many examples throughout the Brigham demonstrating how nurses collaborate with patients and families to improve their experience and ensure they feel welcome, safe, respected and cared for.
It’s who we are.