MedSafe : Reducing Medication Errors in Hospitals

Challenge : Medication errors in hospitals lead to 440,000 deaths each year in the US alone. Our goal was to identify possible factors leading to the errors during nursing rounds and to design a solution to reduce them.
Length of project : 2 months
Location : Georgia Tech & Piedmont Hospital
The project was completed individually. The brief was given to the entire class and we all took separate approaches to the project.

I started the project with secondary research to understand the magnitude of the problem. There were some shocking findings which really motivated me to build an impactful solution.
I spent the next 2 weeks trying to understand lives of nurses in hospitals. Initial secondary research helped identify some of their responsibilities, tasks and tools. We were then introduced to two nurses from Piedmont hospital who gave some great insights about their daily schedules and challenges.

In the next phase, we decided to shadow nurses on their nursing rounds in Piedmont Hospital to do some observational research. The nurses also described their actions and thoughts while we followed them through medication rooms, corridors and patient rooms.
The hospital visits gave some incredible new learnings :
1) Nurses handle up to 5 patients daily. They make up to 4 administration rounds per day per patient. 
2) Medication is stored in a two-factor authenticated room on each floor, serving about 30-40 patients on each floor.
3) Nurses aren't allowed to carry multiple patient's medication at the same time. This means they must visit each patient, go to the medication room, prepare medicine for that patient, take it back to them and then administer.
4) Nurses some times work up to 18 hours a day : most of which is on foot. They may walk up to 6 miles every day and is very fatiguing.
4) Medication rooms are tiny and crowded. They get extremely cramped in peak hours (mornings and evenings).
5) Only one person can access the medication server & preparation table at a time, and its a lengthy process. 
6) A lot of queuing adds to the pressure on the nurse to collect and prepare medicines faster. This leads to anxiety, rush and skipping crucial steps and checks in the process. 
At this stage I found my opportunity space : If I could create a system that would reduce nurse fatigue, anxiety and rush, it would definitely help reduce a lot of medication errors.

To reduce the problems, I would have to redesign the entire flow of nursing rounds. If the medication storage was decentralized, it would help reduce queuing and rush in the room. If the medication was stored directly in the patient room, it would mean reducing the nurses' walking by upto 66%.
At this stage it was informing to look at existing solutions in the market for in-patient room storage. Discovering that Nurse servers attempted to do a similar task, it helped to study them and understand their benefits and failures.
Nurse servers are, essentially, storage drawers built into walls in patient rooms. The major reasons they were not implemented much was : 
1) No tracking of who accessed the medication.
2) Large, bulky and cluttered systems.
3) Huge expenses to setup if added as an afterthought
4) Tough inventory management.
After understanding the goals, constraints and features that my solution needed, I began to ideate on a new nurse server design: 
1) That was smart to allow 2-factor authentication and track access history
2) That was relatively easy and cheaper to install and setup in existing hospital rooms.
3) That would track inventory to simplify restocking issues in existing nurse servers.
After sketching out a few nurse servers that expanded into workstations, I ran into several issues:
1) If the workstation for nurses near patient rooms had to be bigger, they could not stay in corridors as they are narrow.
2) If the workstation and server are inside the patient room, it would take much longer and convolution for the pharmacist to restock medicines.
3) The space needed to build out a system like this would still be relatively large.

And due to these thoughts I had a breakthrough in the project : What if the nurse server was accessible from both inside the patient room and from the corridor? It would mean using much less space in both the room and the corridor, and also make restocking easy.
And to make the access of shelves easy, what if I could use a smarter system which would only let me access the shelf I needed?
MedSafe is a modern, smart nurse server. It's a cylindrical cabinet that mounts into the wall between a patient room and the corridor. 
1) The shelves inside are modular and rotate about a shaft. 
2) You choose what medication you need to access after a 2-step login from the tablet
3) The correct shelf rotates open to you. A green glow highlights the correct drawer.
4) While keeping the medicines on the workstation, the table automatically scans the dosage and kind of the pill, adding a failsafe confirmation.
5) MedSafe keeps track of inventory and all the medicines it has. Syncing with the medication server and patient records, it knows what you need when you need.
6) When inventory for any pill runs low, it alerts the pharmacist who can restock it from the corridor itself.
So finally, MedSafe reduces medication errors arising out of:
 
1) Fatigue, by reducing walking time and distances.
2) Anxiety, by allowing a stress-free atmosphere for preparation.
3) Patient mismatch, by ending the need to carry multiple medications.
4) Medication mismatch, by ensuring scanning at each phase.
 
Features:
 
1) Stores almost all required medication within patient room.
2) Rotating door mechanism ensures storage can be accessed from within the room and the corridor.
3) Modular sizing of shelves allows for storage of multiple formats of medicines.
Thanks for reading! Please reach out to me for more details.

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