Quality Improvement

Medication safety

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Reduction of Pyxis override rates

Reduction of Pyxis override rates

What is Pyxis override?

Pyxis is an automated medicine distribution system.  All inpatient areas within North Shore and Waitakere Hospitals have Pyxis machines.  The machines automate the supply of medicines for individual patients, improving patient safety and reducing waste.

Paper medication charts are faxed to the pharmacy to be profiled into the Pyxis system and validated by a pharmacist.  Ideally, this would occur before a patient receives a  medication for the first time.  There are many barriers to this happening e.g. time of day, bed turnover, length of stay and pharmacy resources.

The override function on the Pyxis machines enables nurses to bypass the pharmacy checks and give patient medications that have not been profiled and validated by a pharmacist.

What are we trying to achieve?

In 2012 the organisation wide override rate was 34%  i.e. a 1 in 3 medicines administered without a clinical check.  One of Waitemata DHB’s key medication safety strategies is to reduce the Pyxis override rate to 30% or less across the organisation, and to 15% or less in key areas.

The principal objectives are to:

  • ensure medicines are administered to patients with appropriate clinical checks in place
  • reduce incidence of patient harm (incorrect dose, time and/or medicine )
  • reduce waste

We undertook a project using the FAST quality improvement methodology.

Our Aim:  Reduce the overall Pyxis override rate to 15% in four "at risk" medical wards at Waitakere Hospital. At the start of this project the override rate for the four pilot wards was 28.5%.

What have we done

Pharmacy and nursing staff worked in focus groups to understand why nurses use the override function.  Through these focus groups:

Charge nurses focus groups in action
Charge nurses
"focus groups in action"

  • We created a common understanding of the need for a clinical check prior to administration
  • Nursing staff understood the importance of faxing the medicine chart to pharmacy when changes are made to the medication chart
  • Pharmacy understood the importance of nursing workflow and medication administration times
  • The causes for the profiling delays were identified and resolved 

The key solution was to disable the override function during business hours.  A permanent override was allowed for select medicines (emergency situations).  In addition:

Pharmacy staff profiling and validating
Pharmacy staff profiling and validating

  • By turning the override function off during business hours nurses have to fax prescriptions to pharmacy prior to administration to a patient
  • By understanding when nurses need to give medications to patients, pharmacy adapted their workflow to meet these needs. This ensured there were no delays
  • Nursing staff agreed to phone pharmacy in urgent situations only, to prevent unnecessary interruptions/ delays and facilitate a smooth workflow
  • Pharmacy are opening earlier to ensure 8.00am medications are given safely
  • All fax machines are pre-set with a speed dial to pharmacy, time stamped and delivered to a dedicated fax machine
  • Pink paper is used in the fax machine for ‘at risk’ patients to ensure early identification by pharmacy

Did we make a difference?

The following chart shows that before we made any changes the override rate was consistently over 20% with an average of 25%.  After we made changes the override rates reduced to an average of 14.98% and the graph also shows that we have managed to maintain this improvement over time

Pyxis control chart

Deliverable / Outcome 1

Four wards collectively meet the target of an override rate of 15% or less and this has been sustained

Deliverable / Outcome 2

Nursing staff report improved inter professional collaboration and an improved process

Pharmacist feedbackNurses feedback

Ultimately we improved workflow, time management and clinical communication