Patient Safety Stories: How One Hospital Leveraged Interdisciplinary Collaboration to Tackle a Flawed Medication Management System

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.

Chief among these system-level issues: medication not being available at the time due, medication not being available in the automatic dispensing cabinet (ADC), and medication not being available in the refrigerator (combined, accounting for 55 of 70 events studied). To address issues, the team determined it would need to change current operating policies and secure a small operational investment. For example, the team hoped to:

  • delineate the medication stock in ADCs to allow for a prospective utilization instead of using the ADC retrospective “critical low” report; and
  • remove the refrigerator form the ADC tower and obtain a remote lock to utilize a larger refrigerator that was already present in the medication room, allowing for a single source of refrigerated medication stock including patient specific and stock medications.

While the team had hoped to enact these changes to reduce events by 30 percent in three months, the project ended up taking a bit longer due to the need to allocate funds (although, luckily, due to executive buy-in, this was less of a challenge than expected) and receive product from the ADC vendor. In the end, the team reduced events from 0.34 to 0.14 per patient day – an 86 % reduction. Further, based on a Cost of Poor Quality (COPQ) metric, looking at potential lost man hours and product as a result of the events, it’s anticipated the collaborative solutions saved the hospital $19,400 a year.

While my team was quite proud of the benefits to the hospital, we also took away some important lessons about what it takes to systemically improve patient safety: 1) when possible, secure executive buy-in to eliminate road blocks, and 2) engage those experiencing the problem in developing the solution (in this case, not only did the nurses provide critical insight to the solutions team, but the process also helped to enhance understanding and mend relationships between them and the pharmacy department). Small and large hospitals alike may apply this approach and these learnings in their own facilities to tackle a range of patient safety issues.

Kenneth Maxik has worked with interdisciplinary hospital teams for more than 20 years on quality, patient safety and compliance. In his role as director of patient safety at CompleteRx — a hospital pharmacy management and patient care company — Mr. Maxik develops and annually updates a proprietary 250-point patient safety checklist for clients, including medical error measures, leveraging the data he collects to recommend protocols that improve patient safety at client facilities.