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Project Final Report

General Information:
Project name:____CTU Pharmacy Expense Education_____________________________
Project Manager Name: ____Lindsay Vasquez___________ Date of Report__11/22/2015______
A. Project Overview: Describe the final product or the service of the
project, the reason the project was undertaken, and the purpose of the
project. Include a description of the problem that was solved by
implementing this project.
The main focus of my project was education of frontline staff on the
pharmacy expenses incurred by the hospital and the patients on our
cardiothoracic unit due to improper medication management. Throughout
this journey I would constantly hear nurses were already aware that
medication was being wasted on our unit, but did not realize the financial
impact it had on the organization and the patients and their families. They
simply did not grasp the amount of waste that was occurring. There was a
central issue everyone recognized but no initiative had been taken to
address the problem. To start I conducted an audit, or collection of data, to
demonstrate how the implementation of changes could improve the amount
of money being spent on medications. I included this data in my presentation
to staff and it was extremely impactful in demonstrating room for
improvement. The thousands of dollars that were becoming an expense to
the patients on a daily basis due to personal practice was enough to
stimulate change. There was an overall positive response to the mandatory
education and staff was willing to modify their practice if it was going to
benefit the patients. Many felt the information was very useful and were

elated that the matter was finally being addressed. Staff now has the tools
and knowledge on where to find cost information on medications and how
and when these medications are charged. I am happy to report that the
follow-up data on medication waste was markedly improved from the
beginning data.
B. Project Goal(s) and Objectives/Deliverables: Identify the goal(s) and objectives met during
this project and compare to the goals and objectives of the Project Scope and Plan. Discuss any
unmet objectives and provide a rationale for lack of completion.
For this project, I was very pleased with the percentage of objectives that were completed.
The goals were met and it was an overall success. My project goals were as follows: Provide
thorough,formaleducationtonursingstaffonpharmacyexpensesforbothpatientsandthe
organizationasawholeinordertoimprovethemedicationmanagementandresource
allocationonourcardiothoracicunitanddecreaseexpensesforpatientsandthepharmacy
departmentbyNovember16,2015.Thecollectionofdataatthebeginningandendingofthe
projectwilldemonstratemarkedimprovementinthepharmacyexpensesontheunitby
November16,2015.Thesegoalswereaccomplishedplusadditionalareasforimprovementwere
identified.
Objective/Deliverables
1. Review current literature on medication/pharmacy expenditures in the inpatient setting
and solutions to these situations in other organizations by September 16, 2015.
A thorough literature review was completed to make sure I was bringing solutions to this
issue that would work. I wanted to obtain information where previous hospitals have
successively dealt with excessive pharmacy expenses before. One of the main articles
that directed my objectives highlighted a study from Trinity Regional Health System in

Illinois. They were successful in recovery large sums of money by improved utilization
(Bates & Richards, 2013).
2. Establish project team members and contacts by September 23, 2015.
I believe the team I established was highly interdisciplinary and involved all the
subspecialties needed to address this issue. The main collaboration was between members
of our cardiothoracic unit and the pharmacy department. There were some issues with
how timely pharmacy responded to my requests for data delaying my formation of
education at times. Most of the communication between pharmacy and myself was done
via email. The bedside nurse I had recruited to help with the visual aids placed in each
room was unavailable during the entirety of the project due to a vacation in Greece.
3. Obtain baseline data on A2 medication management by October 5, 2015.
This was a labor-intensive process that required many hours spent counting and adding
up costs of medications. I was happy with the data I obtained because it was so impactful.
4. Educate on cost of medications commonly used on A2 and the impact these expenses
have on the patient and the hospital by October 23, 2015.
TheeducationpieceofmyprojectwasawellthoughtoutPowerPointconsistingofthe
dataIhadcollectedatthebeginningoftheproject.Itcontainedfifteenslideswith
pictures,graphs,andideasonwhatimprovementlookslike.
5. Create an electronic task in Powerchart or, if not possible, a visual reminder to return
meds to pharmacy by October 28, 2015.
This objective was not entirely met. In the timeframe of this semester is was not possible
to create an electronic task that would fire to nursing twice a day reminding them to
returned unused or expired medications. The I.S. department has simply too many
requests to fulfill that had a much higher priority. My solution to this problem, which I
planned for just in case, was to make visual reminders that would be prominently
displayed in each room. I was able to accomplish this and this was the result:

A sign that reads; check your drawers at 5am and 5pm and returned any unused/expired
meds to pharmacy. Staff liked this visual reminder that was placed so closely to the
medication drawers.
6. Educate on new actions and processes to be put in place to improve compliance with
responsible medication management by October 30, 2015.
This objective was accomplished by verbally reminding staff when I found these
medications in the nurse servers following the required education. By that point, all staff
members had viewed the PowerPoint and should have adjusted their practice. This
objective was mainly holding staff accountable for doing their part. Introducing the signs
in the room was also a new process change and during these times of day, I made it a
point to check the medication drawers for noncompliance. There was no excuse for not
following through when the visual reminders were literally right in front of them.
7. Obtain follow-up data marking the progress of medication management on A2 by
November 14, 2015.
I was able to meet this objective but not as thoroughly as I would have liked. During my
initial collection of data at the start of the project, I was able to audit the medication
drawers a total of seven days. At the end, I was only able to collect data a total of five

days. Time constraints were a barrier in collecting more data due to the pressure to close
the project.
C. Comments: Include any information helpful to understanding the
completion (or lack of completion), major problems encountered and how
they were resolved, risk events that need further explanation, and ethical
issues encountered and addressed.
One of the biggest obstacles encountered is the information that was
obtained from the pharmacist. In the beginning of the project there was
misunderstanding on how the cost of medications was going to be utilized.
She felt that it would be a risk publicizing, even if just to staff, the differences
in cost of medications for the hospital and what is charged to the patient. I
had to fully explain to her that pointing out this difference was not at all my
goal, as it was not in the objectives of this project. She felt that if this
information became available to the general public it could cause a lot of
turmoil for the hospital, fearing that the community would not understand
why there is such a difference (cost to prepare, cost to administer, cost to
package, etc.). After many emails and communication, I conveyed to her that
I was not going to display the cost of medication item by item; I was going to
have an overall value for the hospital costs and the patient costs on a daily
basis. We came to a consensus on how this information was going to be used
and felt we could both move forward with the project.
Another problem I encountered was the lack of help when it came to
creating the visual aids. My bedside staff member that volunteered to help
with this bowed out at the last minute due to a vacation. I had to make extra

time to complete these signs and at times it proved to be a struggle to get


the rest of my activities accomplished.
The biggest ethical issue that I dealt with in this project was justice. Our
units improper medication management was sucking resources from other
areas of the organization. Because pharmacy and unit expenses were
increased, money had to be taken from other areas of the budget. For
example, some of the convenient hygiene products or luxury items had to be
cut. This affected other areas of care for our patients. It also affected the
availability of medications to other units. The fourth ethical principle,
justice, means giving each person or group what he/she or they are due. It
can be measured in terms of fairness, equality, need or any other criterion
that is material to the justice decision. In nursing, justice often focuses on
equitable access to care and on equitable scarce resource allocation (Silva
& Ludwick, 1999). It was vital that we fix this issue because it was an
expense that was modifiable and other areas of patient care could improve
and medications would be equally available to all patients on all units.
D. Recommendations from team members, project manager and site
representative: Identification and discussion of recommendations for
future projects or potential new projects based on the outcome(s) of this
completed project. Includes recommendations from project manager, team
members, and site representative, identifying the source of the
recommendation. Includes supporting scholarly literature or data specific to
future projects.
This project was key in stimulating some changes in some common
medication dispensing practices that are going to save the organization
thousands of dollars on an annual basis. Nitroprusside, a powerful vasoactive

medication, was being dispensed in our postoperative medication kit at a


higher volume than was most often needed to treat postoperative
hypertension. It is crucial in preventing postoperative bleeding due to strain
on graft and valve suture lines and cannulation sites. Staff felt we could not
eliminate this med due to the urgency in which it is needed, but we
successfully cut the amount of drug used in half. This allowed enough time to
obtain more medication from pharmacy if it was actually being used. This
change cut the cost of the medication from around $800/$2,700 to
$400/$1,350 for the hospital and patient respectively. In the future, our openheart program may look at changing this medication all together. There has
been evidence that there are better medications available to treat
postoperative hypertension in this patient population. By inhibiting hypoxic
pulmonary vasoconstriction and increasing blood flow to areas of the lung
with a low ventilation/perfusion (V/Q) ratio, nitroglycerin and sodium
nitroprusside may worsen arterial oxygenation and delay the weaning of
patients from mechanical ventilation. We hypothesized that postcardiac
surgical patients requiring a high FIO2 as well as nitroglycerin and/or sodium
nitroprusside to control hypertension would have an improvement in PaO2
and a reduction in venous admixture if these agents were discontinued
(Wood, 1997). To explain, there are benefits to completely eliminating this
medication in our standard protocol and stimulated by this recent change,
pharmacy is trying even more diligently to prove this evidence to the
cardiothoracic surgeons. It is extremely hard to break old habits, and this is

often the case with medications that surgeons are comfortable using. It is
extremely difficult to present more suitable medications when they believe
what they have works just fine; they are stuck in their old-school ways, so
to speak. I am glad this project has brought this matter to light and in the
near future the quality and effectiveness of medications for our patients,
with pharmacy efforts, only stands to improve.
One of the bedside nurses, after the implementation of the project,
brought another frustration to my attention in terms of medication
management on our unit. She felt there was a great need for change in the
dispensing of Novolog insulin pens on our unit. Insulin orders for our patient
population are constantly being adjusted. Every time the orders were
changed, new insulin pens were being dispensed, even if a new pen was not
needed. Multiple pens were being opened and used in patient medication
drawers, often times only a few units out of each because staff did not
realize another pen was already opened. This led to a high amount of
medication waste when the patient was discharged. These are a high-ticket
item for the hospital and this observation was brought back to the pharmacy
department. A work group was started to address how and when insulin pens
will be dispensed. For those nurses that practiced about five to ten years
ago, insulin vials were far more common and more time consuming to use. It
was a relief for many nurses when insulin pens were becoming more
common in the inpatient setting; mistakes in insulin administration also went
down. In addition, Insulin pens provide DM patients with a number of

advantages over a vial and syringe and can often help them overcome major
barriers to the initiation of insulin therapy. The use of insulin pens leads to
increased patient compliance and potential improvements in glycosylated
hemoglobin (Magnolti & Rayfield, 2007). As with any prepackaged product,
the cost of these pens was higher than the vials. This creates an opportunity
for waste costing the hospital a lot of money. I am participating on a panel
addressing this issue on November 30th of this year to improve the
dispensing process and will be curious with the solutions we come up with
collectively.
E. Interdisciplinary Collaboration: Description of roles and activities each
team member contributed to the project.
J.R.: As a clinical resource nurse clinician and main educator on our nursing
unit, this team member was key in rolling out my education to staff. I was
able to collaboratively find the best avenue to reach all the needed staff
members who handle medications on a daily basis. She was also
instrumental in approving that this education be mandatory and not
voluntary. She saw the value in my project and felt the information was
important enough to make every nurse on the unit view my presentation.
E.V.: This team member functioned in more of an observatory role but was
extremely supportive of all my initiatives on the unit. She was the final say in
the content of my presentation and the appearance of my visual signage.
E.P.: This bedside co-worker was an important asset for me to bounce my
ideas off of. She made suggestions for the format of my presentation in what

she felt would be best responded to. Even though she was unavailable to
physically create the signage I needed, she helped design how they would
look.
D.C.: This pharmacist was key in obtaining my needed data for this project
and initiating the change in concentration of the Nitroprusside drip used
postoperatively. Without her information, my data collection would have
been null. She was also very important in conveying the interest of the
pharmacy department in the implementation of my project because there
were further implications beyond our single nursing unit.
Lindsay Vasquez: I brought most of the project pieces together and made
sure the project adhered to its deadlines. Collecting the data and formatting
the presentation were also large tasks that I completed.
F. Quality Assurance: Document acceptance of the project by the respective nurse
manager/supervisor. Submit Project Evaluation Form to be completed by nurse
manage/supervisor, incorporated into this report and returned to faculty by assigned due date.
I could not have had a better support system for this project! As you can see with my
evaluation, my site representative and unit manager were extremely excited I took this project on
and saw the significance and importance in the material from the beginning.

G. Time log: During week 5 you developed a method to record your time on this project. Please
attached completed time log or copy and paste into this document. Time log must clearly identify
hours spent on the project and the total hours added and documented.
Objective #1: Research
Tasks
Time
Review current literature on solutions 7.0 hours
to reducing pharmacy expenditures
in the inpatient setting.
Objective #2: Establish Team Members
Tasks
Time
Sending out Emails
1.0 hour
Personal communication via meetings 3.0 hours
Objective #3: Obtain Baseline Data
Tasks
Time
Collect Baseline Numbers for unused
10.0 hours
or expired medications left in the
nurse servers, covering both shifts
and doing so conspicuously
Compile medication data
2.0 hours
Research cost of each medication by
3.0 hours
contact with pharmacist
Calculate the amount, in dollars, of
4.0 hours
medication wasted on a daily basis
and transition this information to
graph format
Objective #4: Education on Pharmacy Expense
Tasks
Time
Create a list of commonly used
2.0 hours
medications used on A2
Create Presentation
20.0 hours
Present Education to all staff
4.0 hours
Follow-up with compliance of all staff 3.0 hours
on mandatory education
Objective #5: Create visual reminder
Tasks
Time
Create new visual signage
8.0 hours
Hang signage on unit
2.0 hours

Objective #6: Educate on new Processes


Tasks
Time
Spend time on the floor reminding
8.0 hours
staff to return medications
Objective #7: Collect Follow-Up Data
Tasks
Time
Perform follow-up analysis by
8.0 hours
collecting compliance data
Create Achievement Presentation
6.0 hours
Present to staff members
2.0 hours
Total: 93 hours
References
Bates, C. & Richards, B. S. (2013). Healthcare Cost Containment: Reducing pharmacy costs
through improved utilization. Healthcare Financial Management, 67(6), 106-111.
Magnolti, M. A. & Rayfield, E. J. (2007). An update on insulin injection devices. Insulin, 2(4),
173-181.
Silva, M. C. & Ludwick, R. (1999). Ethics: Interstate Nursing Practice and Regulation: ethical
issues for the 21st century. Online Journal of Issues in Nursing, 4(2). Retrieved from
http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/O
JIN/Columns/Ethics/InterstateNursingPracticeandRegulation.html
Wood, G. (1997). Effect of antihypertensive agents on the arterial partial pressure of oxygen and
venous admixture after cardiac surgery. Critical Care Medicine, 25(11), 1807-1812.

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