and efficiency to the medication process. In summary, the initiative seeks to ensure the five “rights” of medication safety: the right dose of the right drug through the right route at the right time to the right patient.

The Sisters of Mercy Health System, St. Louis, with hospitals in four states, began implementing Mercy Meds in the fall of 2003 and expects to complete its introduction at 10 facilities across Mercy by the end of 2004.

According to the 1999 Institute of Medicine (IOM) report, “To Err is Human,” an estimated 7,000 deaths occur annually in U.S. hospitals as a result of preventable medication errors. Adverse medication events occur for a variety of reasons – for example, failure to distinguish between look-alike packages and sound-alike names such as Celebrex, an anti-inflammatory agent, and Cerebyx, a seizure disorder medication. The growing number of new medications introduced to the market every year also challenge the ability of clinicians to keep current with drug information. Insufficient drug information has been identified as the most common system failure attributing to medication events.

Mercy Meds was born out of a vision developed in the fall of 2001 by Mercy pharmacy directors and other key stakeholders, who met to discuss improvements to the structure of pharmacy services within Mercy hospitals. From that initial meeting, five key strategies were defined:

• Acquiring advanced information systems and automation technology to reduce the possibility of human error in prescribing and administering medications.
• Managing knowledge by sharing information, ideas, protocols and best practices throughout Mercy’s pharmacies.
• Retaining and recruiting pharmacists by increasing their level of job satisfaction and providing continuing education and training opportunities.
• Developing a collaborative-care model of practice by shifting pharmacists’ responsibilities from primarily distributive functions to becoming an integral part of the patient care team.
• Improving contract and formulary management through shared contract and cost information.

By March 2002, Mercy’s Leadership Council had endorsed the pharmacy vision. A business plan was approved by December 2002, and work began to develop the individual elements needed to restructure pharmacy services across Mercy. As the process evolved, it became apparent that the initiative was more than a transformation of pharmacy services – it was an opportunity to transform the entire medication use process. The redesign became a collaborative effort involving hundreds of clinicians and other co-workers across Mercy, including pharmacists, nurses, physicians, information technologists, process improvement experts and supply chain specialists. Multidisciplinary teams were formed to focus on specific aspects of the medication process: (1) pharmaceutical distribution, (2) bar-coding/repackaging, (3) automated cabinetry, (4) bar-code point-of-care technology, and (5) clinical pharmacy and knowledge management strategies.

Over the next year, the teams worked diligently to design and build new processes, acquire and implement the necessary technology, and provide co-worker training and education to comprehensively address the issue of medication safety. When the first Mercy hospital went “live” with Mercy Meds in the fall of 2003, virtually every aspect of the medication use process – from streamlining how medications are acquired to improving the documentation process – had been transformed.

Step-by-Step Redesign
The newly designed process begins at Mercy’s Consolidated Services Center (CSC) in Springfield, Missouri, which serves as a centralized warehouse and distribution center for the entire Mercy organization. As part of the Mercy Meds initiative, Mercy took the unique step of becoming its own pharmaceutical distributor. Through a partnership with the nation’s largest pharmaceutical wholesaler, AmerisourceBergen, the CSC purchases, stores, repackages, bar-codes and distributes pharmaceuticals used across Mercy. In order to take on these tasks, Mercy completed arduous licensing and qualification procedures by federal and state agencies, including the Drug Enforcement Administration and various state boards.

Security and quality are key components of the CSC’s pharmacy operation. About $5 million in drug inventory is protected by an advanced security system, including 16 cameras, motion detectors and electric beams, and a vault for controlled substances. Quality measures include rigorous procedures to ensure the integrity and accuracy of the drug repackaging and distribution processes. With all of these quality controls in place, repackaged medications still must pass a final inspection by a licensed pharmacist prior to distribution to a Mercy facility.

The CSC receives pharmaceutical orders through Mercy’s electronic ordering system and distributes medications daily to hospitals across Mercy using a fleet of secure vehicles and temperature-controlled storage units. At the hospital, the next step in the newly designed Mercy Meds process begins. Instead of storing all pharmaceuticals in a central hospital pharmacy, many medications can now be stored on the nursing unit in computerized drug cabinets. These cabinets securely store up to 300 different unit-dose, bar-coded medications. The availability of drugs on the nursing floor allows nurses to obtain medications in a timely manner once the physician’s order has been verified by a pharmacist. This reduces the work performed by pharmacists to dispense medication orders from a central pharmacy. In addition, the cabinets automate the management of drug inventory and can electronically reorder bar-coded drugs directly from the CSC.

The safety aspects of Mercy Meds hinge on pharmaceuticals being distributed in unit-dose, bar-coded packaging. Bar-coding enables the point-of-care medication verification process that nurses use to administer medications to patients. From a computer that can be moved from patient room to room, nurses use a handheld scanner to scan their own ID badge, the patient’s ID wrist band, and the medication packaging to verify accuracy. All of the “five rights” of medication administration must be in place for the bar-coding technology to accept the order: the dose, drug, route of administration, time and patient. If any of the rights are not verified, the system issues an alert. In addition to verifying medication accuracy, the computer automatically updates the patient medication administration record in real time. Links to online drug reference resources also are readily available via the computerized technology.

Education has been an important aspect of introducing Mercy Meds across Mercy. Within each facility, nursing “super users” have been selected and trained on the technology and serve as experts during the introduction of the new processes and technology on nursing units. Clinical pharmacy coordinators have been appointed or hired within each facility to guide pharmacy-related training and education. As the roll-out has progressed, learnings from each facility have been shared with other facilities yet to implement Mercy Meds. The emphasis on education and collaboration has further strengthened the medication transformation experience.

A True Team Effort
The design of Mercy Meds has truly been a multidisciplinary effort involving knowledge experts from across Mercy. The initiative has reached far beyond the involvement of traditional practitioners and leaders to realize the full benefits of collaborative medication transformation. For example:

• Process improvement co-workers worked diligently to conduct current state assessments in hospitals and develop gap analyses relevant to future state design.
• Supply chain specialists enhanced Mercy’s existing distribution operation to enable the addition of pharmaceuticals and implemented a centralized repackaging and bar-coding operation.
• Legal services assisted with the licensing of operations at the state and federal levels.
• Human Resources developed pharmacy-related retention and recruitment strategies and implemented processes to enable the bar-coding of co-worker badges.
• Engineering and maintenance specialists completed a variety of construction-related projects.
• Pharmacists participated in the implementation of distribution process changes, including the deployment of automated dispensing cabinets and development of bar-coding processes. In addition, they worked collaboratively to enrich pharmacy education and enhance access to drug information.
• Nurses worked jointly with pharmacy team members to design processes for medication distribution, administration and monitoring. They also helped in the selection of hardware, computer carts and stands, and other devices needed to support Mercy Meds.
• Information technology experts played a key role in identifying hardware and software requirements, designing and integrating systems, and installing wireless networks.
• Physicians participated in protocol development, contracting and formulary management decisions.
• Executive leadership across Mercy supported the initiative as a priority and enabled the removal of potential barriers and the achievement of aggressive timelines.

The Initiative "Goes Live"
In early December 2003, Mercy Meds was introduced on the neurology and pediatric floors of St. John’s Mercy Medical Center in St. Louis. As the first step in Mercy’s actual implementation of the medication transformation initiative, the “go-live” provided Mercy with the experience of using the new technology and processes in a patient care setting and brought to light the need for further modifications and process improvements. More importantly, it clearly demonstrated the ability of Mercy Meds to detect potential medication errors and improve patient safety.

As of October 2004, Mercy Meds was in service to approximately 900 patient beds at seven facilities across Mercy. To date, detailed prevented administration error data has been reviewed on more than 90,000 administrations and the technology has reportedly prevented 386 potential errors. Mercy Meds also is helping to support an important shift from reactive post-event medication reporting to proactive near-miss reporting, because the point-of-care technology alerts staff prior to a potential medication error. Near-miss data can be analyzed even further to reduce the possibility of future medication events.

Clinical pharmacy services also are beginning to positively impact the medication use process. Through August, more than 50,000 pharmacist encounters have been documented, contributing to improved patient education and safety, cost-effective care and positive clinical outcomes.

The entire Mercy Meds experience has strengthened the sense of “systemness” across Mercy through increased interaction across facilities and professional disciplines, most predominantly nursing and pharmacy. Through process redesign and implementation, co-workers have gained a greater appreciation and understanding of the value of collaboration and coordination, and the benefits that can be achieved.

Co-authors
Kelly Turner
Pharm.D., Senior Consultant/Manager–Pharmacy Services, Sisters of Mercy Health System, St. Louis, Missouri
Barbara Meyer
Executive Director–Corporate Communications, Sisters of Mercy Health System, St. Louis, Missouri
Michele Stewart, M.A., BSN
Vice President–Nursing Services, St. Joseph’s Mercy Health Center, Hot Springs, Arkansas