San Antonio – A novel medicationdelivery system created by a Canadian group of residential care facilities improved overall quality of care while building personal and satisfying relationships between staff and residents, Heather Mak, RN, reported at AMDA Long Term Care – 2012. The program at Providence Health Care in Vancouver was part of a plan to improve quality of life for residents, said Ms. Mak, director of elder palliative services for the company, which provides care to 627 residents at five sites. Over 2 years starting in 2005, the facilities divided 75-bed units into neighborhoods of 22–25 residents each, with staff consistently assigned to each neighborhood, and hired additional nurse assistants. These costs were offset by a reduction in the number of professional staff members – including registered nurses, physical therapists, and occupational therapists – and transfer of responsibilities such as daily walking and activities (in partnership with rehabilitation assistants) and regularly scheduled medication delivery duties to the nurse assistants (called RCAs in Canada). Medication delivery by RCAs represented the most dramatic change, Ms. Mak said. A design team created the new approach in consultation with key stakeholders and with licensing and regulatory bodies. In addition to the 6-month training course the RCAs normally complete to attain their positions, they underwent special training in medication delivery. With the change, medication is provided in unit-dose packages and delivered to personal medication cupboards, each labeled with the patient’s photo, at residents’ bedsides. The RCAs deliver 80% of the medication residents take, including all regularly scheduled oral doses for stable residents, liquid medications including milk of magnesia, docusate, and liquid doses of calcium and vitamins. They also deliver basic eye drops and non-narcotic patches. Registered nurses deliver any medication given within the first 48 hours after admission, all medications within 24 hours of a new prescription or dose change, all p.r.n. medications, all injectable or nebulized medications, all liquids not on the RCA list, and any narcotic patches or prescription eye drops. Staff participate in ongoing education about their roles. Ms. Mak noted that once initial classroom training is completed, staff must pass a written test, demonstrate their skills, and successfully deliver medication to two residents under supervision. A checklist is used to assess compliance with the process. Soon after the program began, the facilities noted that while medication errors with severity scores of 3–5 changed very little under the new system, errors related to omissions – with severity scores of 0–2 – increased dramatically. Ms. Mak said that this was due in part to the fact that such errors were very obvious in the medication cupboards. Nonetheless, the problem was concerning, and the Providence facilities strived to create a “culture of reporting” and a no-blame approach, said Ms. Mak. “One thing we learned was that nurses were used to having worksheets, but unregulated providers [RCAs] had never used anything like that,” she said. Their typical duties, such as bathing of residents, were regimens that they just “kept in their head.” This approach wasn’t working when it came to medication delivery, so a reminder sheet was developed for the RCAs. Additional efforts were intense analysis of the RCAs’ overall workflow; making the medication cupboards uniform by, for instance, removing clutter; conducting time and motion studies; and engaging the RCAs in a nursing-practice council and pharmacy-nursing committee. The result has been a decline in medication incidents of omission, an increase in the number of direct-care hours provided daily by the RCAs, development of relationships between caregivers and residents and families, and a staff passionate about quality, Ms. Mak said. The efforts to improve quality of care are ongoing, she added. “I don’t think for us the conversation will ever end.” CfA