Metropolitan King County Council
King County Auditor’s Office
Cheryle A. Broom, King County Auditor
King County Courthouse
516 Third Avenue, Room W1033
Seattle, WA 98104-3272
206.296.1655 Fax 206.296.0159
TTY 296-1024
www.metrokc.gov/auditor

MEMORANDUM
DATE:
TO:
FROM:
SUBJECT:

October 9, 2007
Metropolitan King County Councilmembers
Cheryle A. Broom, County Auditor
Jail Health Services Pharmacy Operations and Medication Administration
Performance Audit

Attached for your review is the Jail Health Services Pharmacy Operations and Medication
Administration Performance Audit. The objective of the audit was to evaluate Jail Health
Services’ controls over medications (including narcotics and other controlled substances),
assess the effectiveness of quality assurance activities, and review staffing and scopes of
practice within the context of medication administration and pharmacy operations.
The general audit conclusion was that Jail Health Services’ (JHS) patients are at no greater risk
due to medication errors than patients in other healthcare settings. However, opportunities exist
for JHS to increase accountability in its medication processes. With regard to staffing, we found
that JHS has developed a viable staffing model based on workload and productivity data for
pharmacy shifts and has begun to do so for nursing. We also found that the new Electronic
Health Record system at JHS should provide program staff with the workload and productivity
data necessary to strengthen current nurse staffing practices.
The County Executive concurred with the audit findings and recommendations. The executive’s
official response is included in the appendices of this report.
The auditor’s office sincerely appreciates the cooperation received from the staff and
management of Jail Health Services and the Department of Adult and Juvenile Detention.
CB:CD:jl

PERFORMANCE AUDIT
JAIL HEALTH SERVICES’
PHARMACY OPERATIONS &
MEDICATION ADMINISTRATION

Presented to
the Metropolitan King County Council
General Government and Labor Relations Committee
by the
County Auditor’s Office

Cheryle A. Broom, King County Auditor
Wendy Soo Hoo, Senior Management Auditor
Cindy Drake, Senior Management Auditor
Allan Thompson, Senior Financial Auditor

Report No. 2007-04
October 9, 2007

Auditor’s Office Mission
We conduct audits and studies that identify and recommend ways to improve accountability,
performance, and efficiency of county government.

Auditor’s Office Vision
We are committed to producing substantive work of the highest quality and integrity that results in
significant improvements in accountability, performance, and efficiency of county government. We
share a commitment to our mission, to our profession, and to a collaborative work environment in
which we challenge ourselves to accomplish significant improvements in the performance of the
King County Auditor’s Office.

™
The King County Auditor's Office

through independent audits and other

was created in 1969 by the King County

studies regarding the performance and

Home Rule Charter as an independent

efficiency of agencies and programs,

agency within the legislative branch of

compliance with mandates, and integrity of

county government. Under the provisions of

financial management systems. The office

the charter, the County Auditor is appointed

reports the results of each audit or study to

by the Metropolitan King County Council.

the Metropolitan King County Council.
The King County Auditor’s Office

The King County Code contains policies and

performs its work in accordance with

administrative rules for the Auditor's Office.
The King County Auditor's Office

applicable Government Auditing Standards.

provides oversight of county government

™
Audit and study reports are available on our Web site (www.metrokc.gov/auditor) in two formats: entire
reports in PDF format (1999 to present) and report summaries (1992 to present). Copies of reports can also
be requested by mail at 516 Third Avenue, Rm. W-1033, Seattle, WA 98104, or by phone at 206-296-1655.

Alternative Formats Available Upon Request

TABLE OF CONTENTS
PAGE

Executive Summary

ii

Chapters
Chapter 1

Introduction and Background

1

Chapter 2

Pharmacy and Medication Administration Processes

7

Chapter 3

Nursing and Pharmacy Staffing

33

Exhibit A

2004 – 2006 Medication-Related Inmate Complaints to King
County Ombudsman’s Office

10

Exhibit B

Jail Health Services Medication Incident Reports

12

Exhibit C

Medication Incidents Categorized by Process Step

14

Exhibit D

Jail Health Services’ Current Pharmacy and Medication
Administration Operating Model

17

Exhibit E

Identification of Key Handoffs Between Pharmacy and Nursing

18

Exhibit F

Comparison of Jail Health Services Quality Improvement
Program Practice to Best Practices

28

Exhibit G

Jail Health Services Prescription Volumes, 2003–2006

35

Exhibit H

Percentage of Inmates Receiving a Prescription, KCCF and RJC
April 1–14, 2003–2007

36

Exhibit I

Average Daily Population, KCCF and RJC 2003–2006

36

Exhibit J

Current Jail Health Services Nurse Staffing Matrix Registered
Nurse (RN) and Licensed Practical Nurse (LPN) Full-Time
Equivalents

40

Exhibit K

Vacancy Rates for Nursing Positions

45

Exhibit L

2006 Average Cost per Hour Worked of Jail Health Services
Registered Nurses (RN)

51

Exhibit M

JHS Nursing Hours, 2005 - 2006

53

Appendix 1

2004 – 2006 Medication-Related Inmate Complaints to King
County Ombudsman’s Office

57

Appendix 2

Jail Health Services Medication Incident Reports

59

Exhibits

Appendices

List of Findings, Recommendations & Implementation Schedule

61

Executive Response

65

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EXECUTIVE SUMMARY
Introduction
Audit Conducted in

This performance audit was conducted in response to a motion

Response to

passed by the King County Council directing the King County

Ombudsman’s

Auditor’s Office to review Jail Health Services’ pharmacy

Concerns about

operations and medication administration practices. The council’s

Medication

concerns focused on issues raised in the King County

Administration

Ombudsman’s Office November 2006 Report on Jail Health

Practices

Medication Errors and State Inspection Results. Key issues
raised in the Ombudsman’s report included:
ƒ

Inmate complaints regarding the timeliness and accuracy of
medication administration;

ƒ

Jail Health Services staff concerns regarding heavy
workloads, understaffing, reliance on temporary agency
nurses, and an ineffective quality improvement program; and

ƒ

Washington state Board of Pharmacy inspection report
findings citing medication-related process deficiencies from
2004, 2005, and 2006.

General Conclusions
Overall, we found that Jail Health Services’ patients are at no
greater risk due to medication errors than patients in other
healthcare settings. However, opportunities exist for Jail Health
Services to increase accountability in its medication processes.
With regard to staffing, we found that Jail Health Services (JHS)
has developed a staffing model based on workload and
productivity data for pharmacy shifts and has begun to do so for
nursing. Implementation of the new Electronic Health Record
system by JHS should provide program staff with the workload
and productivity data necessary to strengthen current nurse
staffing practices.

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Executive Summary

Scope and Objectives
This performance audit evaluated Jail Health Services’
medication administration and pharmacy operations, including an
independent evaluation of the quality, accuracy, and efficiency of
practices. The objectives were to evaluate Jail Health Services’
medication-related processes, quality assurance activities, and
staffing and workload trends.
Summary of Key Findings
Inmate Safety Is at No

Our consultant’s assessment of pharmacy operations and

Greater Risk Due to

medication administration processes identified the need for

Medication Errors than

additional controls over medications. Their review also concluded

Patients in Other

that county inmates are at no greater risk of harm due to

Healthcare Settings

medication errors than patients in other healthcare settings.

Opportunities Exist to

Within the current operating model, there are opportunities for

Improve Medication

medications to be lost, and no controls or limited controls exist to

Accountability

detect and monitor such events. Additional controls for narcotics
are in place, but these controls could be strengthened.
Another notable theme highlighted during our audit was that the
primary mission of a jail is to secure custody, not to provide
health services. These disparate objectives make it critical for
correctional staff and healthcare staff to coordinate activities.
During our site visits, we observed that opportunities exist for Jail
Health Services and the Department of Adult and Juvenile
Detention (DAJD) to improve collaboration during the medication
administration process.
Finally, our review of Jail Health Services’ quality improvement
program concluded that Jail Health Services is developing and
implementing an array of activities that are consistent with
healthcare industry best practices for quality improvement.
However, our best practices research suggested that

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Executive Summary

performance measures could be strengthened to increase
emphasis on outcomes rather than process outputs.
Pharmacy Staffing

Our audit also reviewed Jail Health Services’ staffing practices.

Model Needs to Be

Although the current pharmacy staffing model is based on an

Updated to Reflect

analysis of workload and productivity data, the model was

Current Processes and

developed prior to significant changes in operations and should

Workload

be updated to ensure it reflects the demands of the current
workload. Additionally, the current pharmacy staffing plan does
not include relief for employees who call in sick or take vacation.

Nurse Staffing Model

Jail Health Services has begun to develop a nurse staffing model

Could Be Improved if It

that is based on nurse workload and productivity; however, the

Were Linked to

limited amount of electronic data accessible to JHS program staff

Workload Demands

has made development of this kind of model difficult. Jail Health

and Productivity Goals

Services is currently replacing its paper-based medical record
system with electronic health records. With the new system,
program staff will be able to access electronic information about
the patients served and the productivity of nurses. Once
workload and productivity data are available, Jail Health Services
needs to evaluate the factors that impact its staffing needs and
link its nurse staffing plan to those factors.

Audit Identified a

Additionally, we identified a pattern of shifts worked by fewer

Pattern of Shifts

nurses than specified in the current staffing plan, particularly at

Worked by Fewer

the King County Correctional Facility (KCCF). Because JHS has

Nurses Than Planned

not set nurse staffing levels using workload and productivity data,
we could not determine whether a shift worked by fewer nurses
than planned is not sufficiently staffed to meet the demands of
the workload. Rather, our results indicate only that nursing shifts
are frequently staffed by fewer nurses than the current plan
specifies. In order to improve staffing on nursing shifts, Jail
Health Services needs to ensure nursing schedules align with
nurse staffing plans; work to reduce vacancies and unscheduled

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Executive Summary

leave; and develop a staffing model that includes coverage for
nurses on leave.
Summary of Key Recommendations
Jail Health Services

We recommended that Jail Health Services enhance

Should Strengthen

accountability for medications by strengthening inventory controls

Inventory Controls and

and transferring responsibility for filling the carts with inmate

Transfer Greater

medications from nursing to pharmacy staff. Additionally, Jail

Responsibility to the

Health Services should conduct a feasibility analysis to evaluate

Pharmacy

centralizing its pharmacy operations.
We also recommend that JHS work with DAJD to modify their
Memorandum of Understanding to include regular joint reviews of
medication administration performance. JHS should identify key
publicly reportable performance measures, including outcomebased measures, and monitor these through the joint Jail Health
Services and DAJD reviews.

Staffing Models Should

Jail Health Services should update its pharmacy staffing model to

be Updated and Linked

ensure it reflects the demands of the current workload and

to Workload Demands

accounts for staff on vacation or sick leave. Nurse staffing should

and Productivity Goals

be improved through development of a model that is
systematically linked to workload demands and productivity
goals. Additionally, JHS should ensure that nurse schedules
align with staffing plans and that the nurse staffing model also
incorporates the need to cover employees on leave.
Jail Health Services should improve its management of vacation
leave by specifying the maximum number of staff who can take
vacation from each shift. JHS should also consider improving
current leave policies to create an incentive for employees to
save their sick leave.

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Executive Summary

Summary of Executive Response
The county executive has provided a response to the
recommendations and concurs with all of them. The response
also includes proposed implementation timelines. See the
appendices section for the complete text of the Executive
Response.
Acknowledgement
The Auditor’s Office appreciates the work of our consultant on
this audit, Westcoast Consulting Group, LLC. We thank the
management and staff of Jail Health Services and Public Health
– Seattle and King County for their cooperation and willingness
to dedicate their time to assist with this audit. We also wish to
acknowledge the information and assistance provided to us by
the King County Ombudsman’s Office.

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1

INTRODUCTION AND BACKGROUND

Audit Conducted in

This performance audit was conducted in response to a motion

Response to Council

passed by the King County Council directing the King County

Motion

Auditor’s Office to review Jail Health Services’ pharmacy
operations and medication administration practices. The council’s
concerns focused on issues raised in the King County
Ombudsman’s Office November 2006 Report on Jail Health
Medication Errors and State Inspection Results. Key issues
raised in the Ombudsman’s report included:
ƒ

Inmate complaints regarding the timeliness and accuracy of
medication administration;

ƒ

Jail Health Services staff concerns regarding heavy
workloads, understaffing, reliance on temporary agency
nurses, and an ineffective quality improvement program; and

ƒ

Washington state Board of Pharmacy inspection report
findings citing medication-related process deficiencies in
2004, 2005, and 2006.

After the Ombudsman’s Office issued its report on medication
concerns, the King County Council requested that the King
County Auditor’s Office conduct a performance audit to confirm
and further assess the problems identified and to determine
whether these problems were the result of systemic weaknesses.
Jail Health Services Overview
Jail Health Services provides health services at the King County
Correctional Facility (KCCF) in Seattle and the Norm Maleng
Regional Justice Center (RJC) in Kent. While the Department of
Adult and Juvenile Detention operates the two jails, Jail Health
Services organizationally resides within Public Health – Seattle

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Introduction

and King County. According to the Hammer settlement
agreement, KCCF must be accredited by the National
Commission on Correctional Health Care (NCCHC). Both jails,
KCCF and RJC, were most recently accredited by NCCHC in
2005; and Jail Health Services and the Department of Adult and
Juvenile Detention are currently preparing for the next
accreditation survey in 2008.
Jail Health Services

Jail Health Services is staffed 24 hours per day, 7 days per

Provides Broad Range

week, and 365 days per year. Jail Health Services provides an

of Health Services

intake health assessment to individuals booked into KCCF and
RJC to identify and respond to health needs during their
incarceration. Additionally, a broad range of health services is
available to all inmates, including:
ƒ

Medication verification

ƒ

Pharmacy services and medication administration

ƒ

Nursing health assessment, monitoring, and treatment

ƒ

Acute medical care

ƒ

Chronic disease management

ƒ

Diagnostic testing and services (lab and x-ray)

ƒ

Emergency care

ƒ

Referral for specialty medical care

ƒ

Infection control and wound care

ƒ

Women’s health care

ƒ

Mental health screening, case management, and crisis
counseling

ƒ

Psychiatric treatment

ƒ

Dental care

ƒ

HIV/Sexually Transmitted Disease testing and counseling

ƒ

Withdrawal management

ƒ

Social work assessment, case management, and release
planning

King County Auditor’s Office

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Chapter 1

Introduction

Jail Health Services Is

Jail Health Services is currently undergoing two major initiatives

Implementing

that significantly impact its operational processes. First, Jail

Electronic Health

Health Services is in the process of implementing an electronic

Records and

health record system (EHR) to replace its existing paper-based

Undergoing a Major

medical record system. The EHR should improve healthcare

Remodel

staff’s access to health care information during clinical
encounters and improve the overall management of patient
information. The new system is expected to streamline work
processes by automating many healthcare functions. For
example, pertinent patient data will be readily available to
healthcare staff without needing to locate a paper chart. The
system also includes automated controls, such as notification
when a staff member does not provide complete information on a
patient’s record.
In addition, KCCF is currently being remodeled as part of the
Integrated Security Project (ISP). The ISP is replacing KCCF’s
electronic security systems and redesigning Jail Health Services’
workspaces, including the addition of a new health assessment
clinic and expansion of the pharmacy. All work is scheduled to be
completed by October 2008.
Ombudsman’s Office 2006 Report
The Ombudsman’s Office regularly receives allegations of
medication errors from inmates, which generally involve the
following issues:

Ombudsman Receives

ƒ

Allegations of
Medication Errors from

Timeliness of verification of outside prescriptions after
booking;

ƒ

Interruptions in supply of prescriptions for critical and noncritical medications;

Inmates
ƒ

Wrong medications being delivered or administered;

ƒ

Timeliness in providing psychiatric evaluations and
medications; and

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Introduction
ƒ

Responses to medication-related kites (requests for medical
service) and grievances.

In addition to complaints from inmates, the Ombudsman’s Office
has also handled issues raised by Jail Health Services staff. In its
November 2006 report, the Ombudsman’s Office discussed JHS
staff allegations that patient care and working conditions have
deteriorated in recent years. Nurses and pharmacists indicated
that workload is increasing and that shifts are frequently shortstaffed.
Finally, the Ombudsman’s Office report summarized recent state
Board of Pharmacy inspection reports, which identified
deficiencies in Jail Health Services practices. 1 The board
inspector’s primary concerns centered on security of pharmacy
and medication rooms, adequacy of controls in the automated
storing and dispensing system, controls for narcotics, issues
related to transfer of inmates between KCCF and RJC, and the
lack of an ongoing quality improvement program.
Audit Scope, Objectives, and Methodology
This performance audit evaluated Jail Health Services’
medication administration and pharmacy operations, including an
independent evaluation of the quality, accuracy, and efficiency of
practices. The audit objectives were to:
1) Evaluate Jail Health Services’ processes for:
ƒ

Securing and tracking of medications, including narcotics
and other controlled substances;

ƒ

Ensuring that critical medications are appropriately
dispensed and distributed; and

ƒ

Monitoring the accuracy of medication dispensation and
distribution.

1

Washington Administrative Code 246-869-190 authorizes the state Board of Pharmacy to periodically inspect
pharmacies to assess their compliance with state laws. The Board of Pharmacy issued non-passing scores to KCCF
in October 2004 and to RJC in March 2006, but it subsequently issued passing scores upon re-inspection.

King County Auditor’s Office

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Chapter 1

Introduction

2) Assess the effectiveness of the Jail Health Services’ quality
assurance activities.
3) Review Jail Health Services staffing and scopes of practice
within the context of medication administration and pharmacy
operations, including reviews of existing policies and
procedures and workload and staffing trends.
We retained a consultant, Westcoast Consulting Group, LLC, to
provide technical and healthcare expertise in the evaluation of
Jail Health Services’ controls over medications.
The methodology included the following audit activities:
ƒ

Reviewing current policies, procedures, and processes for
dispensing and administering medications, as well as
reviewing planned process changes, such as implementation
of electronic health records

ƒ

Reviewing relevant state laws and regulations

ƒ

Interviewing officials and managers from Public Health, Jail
Health Services, and Department of Adult and Juvenile
Detention

ƒ

Shadowing pharmacy and nursing staff and observing actual
practices

ƒ

Surveying other jurisdictions to identify innovative jail
pharmacy and medication administration practices

ƒ

Analyzing available data on medication issues, including Jail
Health Services Medication Incident Report data and
aggregate grievance data, as well as Ombudsman grievance
logs

ƒ

Identifying best practices for healthcare organizations’ quality
assurance programs

ƒ

Analyzing data on workload, including prescription volumes,
average daily inmate population (ADP), and the number of
inmates receiving a prescription, to identify trends

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Introduction
ƒ

Assessing Jail Health Services’ nursing and pharmacy
staffing practices, and determining whether shifts are staffed
in accordance with planned staffing levels

ƒ

Comparing the costs of full-time permanent (career service)
nurses and temporary agency nurses

We conducted this audit in accordance with Generally Accepted
Government Auditing Standards.
Scope of Work on Internal Controls and Data Reliability
During this audit, we evaluated internal controls related to the
audit objectives. Our review of internal controls focused on
controls related to pharmacy operations and medication
administration practices. Our conclusions on the effectiveness of
these controls are detailed in Chapter 2 of this report.
Our analysis relied on computer-generated data related to
prescription volumes, average daily inmate population (ADP),
staff leave usage, and staff attendance. As part of our analysis,
we assessed the reliability and accuracy of the data. We
identified errors in the staff attendance data, but we were able to
work with Jail Health Services to correct the errors. With regard
to the other data sources, we concluded that the data were
sufficiently reliable.

King County Auditor’s Office

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2

PHARMACY AND MEDICATION
ADMINISTRATION PROCESSES
This chapter focuses on Jail Health Services’ processes for
securing and tracking medications, ensuring that critical
medications are appropriately dispensed and distributed, and
monitoring the accuracy of medication dispensation and
distribution. This chapter also discusses Jail Health Services’
quality assurance activities and assesses them in relation to best
practices.
Our audit focused on answering the following questions:
1) Is inmate safety at risk due to Jail Health Services’
medication practices?
2) What are the key causes of medication incidents and errors?
3) Are medications, including narcotics and other controlled
substances, missing or lost?
4) What other process improvements can be implemented to
increase accountability for medications at King County’s jails?
5) How do Jail Health Services practices compare to other jails?
6) What are other jails doing to reduce medication errors?
7) What quality assurance activities does Jail Health Services
engage in and are these activities consistent with best
practices?

Inmates Are Not at

Overall, we found that Jail Health Services’ patients are at no

Greater Risk of

greater risk of medication-related errors than patients in other

Medication Errors

healthcare settings. However, opportunities exist for Jail Health
Services to increase accountability in its medication processes.
Jail Health Services’ Medication Processes
Jail Health Services providers (e.g., physicians or nurse
practitioners) prescribe new medications or prescribe verified

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Pharmacy and Medication Administration Processes

prescriptions from community-based practitioners before they are
dispensed by the pharmacy. Medications are either administered
by nursing staff in single doses or delivered to inmates for selfadministration (keep-on-person), depending on criteria
established by Jail Health Services.
Jail Health Services has recently initiated changes to its
medication administration processes. 2 At the time of the
Ombudsman’s Office report, Jail Health Services’ medication
processes were implemented as follows:
ƒ

Providers submitted an order to the pharmacy for an inmate’s
medication using a paper Medication Order form.

ƒ

The pharmacy printed a Medication Administration Record
(MAR) for each single-dose medication and filled the
medication order. The pharmacy filled up to seven days of
the medication, placed the medication in a plastic bag, and
transferred the MAR and the medication to the medication
cart room. The medication cart room is where nurses prepare
their carts to administer single-dose medications to inmate
housing units (“medication pass”).

ƒ

Nurses typically prepared their carts by tearing off individual
doses from the seven-day supply for each inmate,
transferring the daily doses into a small envelope for each
inmate, and clipping the envelope to the inmate’s MAR.
Nurses would then wheel their carts to the assigned housing
units and administer the medications to each inmate with a
prescription in the housing units. Nurses conduct medication
passes three times each day or more often if needed.

2

Our review of controls over the medication processes primarily focused on medications administered by nurses
(single-dose medications), because of increased opportunities for Jail Health Services staff to err in their
administration.

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Pharmacy and Medication Administration Processes

Key Process

During the audit, Jail Health Services began piloting a key

Improvement Is Being

process improvement at KCCF. The KCCF pharmacy now fills

Piloted at KCCF

and refills each single-dose medication on a one-day basis (“24hour fill”) rather than a seven-day basis. This change was
implemented to:
ƒ

Reduce delays in dosing that can occur when inmates are
transferred between KCCF and RJC,

ƒ

Strengthen medication accountability,

ƒ

Decrease wastage and loss of inventory, and

ƒ

Reduce pharmacy staff time spent investigating and refilling
missing medications, as well as nursing staff time spent
preparing medications.

This new process is discussed in more detail under Question 2
on Page 13.

1. IS INMATE SAFETY AT RISK DUE TO JAIL HEALTH SERVICES’ MEDICATION
PRACTICES?
Our consultant’s assessment of pharmacy operations and
medication administration processes concluded that county
inmates are at no greater risk of harm due to medication errors
than patients in other healthcare settings. This conclusion was
based on an analysis of the two sources of medication error data
that were available to assess patient risk. 3 One source is the
Ombudsman’s Office inmate grievance log that documents
patient complaints. The other source is Jail Health Services
Medication Incident Reports that document incidents reported by
JHS staff whenever a medication problem occurs.

3

A third source of data is the Jail Health Services’ internal grievance logs, which are reviewed as part of its quality
improvement program; but Jail Health Services provided only aggregate grievance totals due to state confidentiality
requirements.

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Pharmacy and Medication Administration Processes

Analysis of the Ombudsman’s Office grievance logs involving Jail
Health Services identified approximately 500 inmate grievances
over a three-year period from January 2004 through November
2006. Of these inmate grievances, our consultants verified that
171 involved specific issues or concerns regarding Jail Health
Services’ medication administration. 4
A Clinical Assessment

For the purposes of this audit, a clinical assessment was

Was Performed to

performed to categorize the complaints based on their severity.

Categorize

Using an industry-wide index for classifying medication errors by

Ombudsman

severity, a registered nurse from the Westcoast Consulting

Grievances

Group reviewed and categorized each of the medication
complaints made to the Ombudsman’s Office from January 2004
through November 2006. The results of this analysis are
summarized in Exhibit A below. (The full results and more
detailed descriptions of each category are included in
Appendix 1.)
EXHIBIT A
2004 – 2006 Medication-Related Inmate Complaints to
King County Ombudsman’s Office
35-Month Total

No Error
Error but No Harm

53

31.1%

111

64.9%

7

4.1%

Error that May Have Contributed to or Caused Harm
Error that Caused Death

-

Total

Percent by Category

171

0%
100%

* Note: Index based on Medication Errors Reporting Methodology by the United States Pharmacopoeia Medication
Error Reporting Program.
SOURCE: King County Ombudsman’s Office complaint logs and Westcoast Consulting Group analysis.

4
The Ombudsman’s Office report identified 192 medication-related complaints from January 2004 through November
2006. Consultants assessed only 171 of these complaints, excluding complaints in which it appeared that the inmate
had not yet seen a provider or been prescribed a medication or for which the logs requested from the Ombudsman’s
Office included only general information about the complaint. The Ombudsman’s Office maintains more detailed
records of complaints in case notes, but those were not reviewed as part of this analysis.

King County Auditor’s Office

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Pharmacy and Medication Administration Processes

Majority of Incidents

As shown in Exhibit A above, 96 percent of the incidents were

Did Not Cause Harm to

not errors or were errors that did not cause harm to the inmate.

the Inmate

The majority of incidents (64.9 percent) were categorized as
errors that reached the inmate, but did not cause harm. These
could include delays in medication administration that occur due
to verification processes or inter-facility transfers. Seven inmates
complained to the Ombudsman’s Office over the last three years
about medication errors that may have contributed to or actually
caused harm, and none of the cases involved deaths. Those
incidents represent 4.1 percent of the medication complaints. 5
Another source of information on medication incidents is Jail
Health Services’ internal medication incident reporting process.
Jail Health Services nursing and pharmacy staff submit
Incident/Accident Reports when they identify medication
incidents and potential errors. Beginning in 2007, nursing
supervisors and the Jail Health Services Medical Director began
to review these reports and categorize each incident’s cause and
severity, using the same national index. The categorizations are
documented on Medication Incident Report forms. 6
Exhibit B below summarizes the Jail Health Services Medication
Incident Report data we analyzed for 2006 and 2007. A more
detailed version is provided in Appendix 2. (A 10-percent random
sample of 2006 Medication Incident Reports was prepared
specifically for the audit.)

5

In assessing the complaints, the consultant categorized incidents in the higher severity category when incidents
could potentially be classified in two different categories based on the available information.
6
Incidents are categorized according to severity based on the United States Pharmacopoeia Medication Error
Reporting Program classifications.

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EXHIBIT B
Jail Health Services Medication Incident Reports
Random
Percent by
Quarter 1
Percent by
Sample
Category
Actuals
Category
2006
2007
2007
2006*
No Error
7
10.6%
28
17.7%
Error but No Harm
59
89.4%
128
81.0%
Error that May
Have Contributed to
0
0.0%
2
1.3%
or Caused Harm
Error that Caused
0
0.0%
0
0.0%
Death
Total
66
100%
158
100%
* Note: A sample of 75 incidents was initially selected for analysis, but eight had been
mistakenly categorized as medication-related, and a ninth incident could not be categorized
according to the medication error index using available information. The audit team,
including a registered nurse from Westcoast Consulting Group, observed and validated Jail
Health Services’ process for categorizing select incidents for the 2006 sample.
SOURCE: Medication Incident Reports prepared by Jail Health Services.

Jail Health Services’

Jail Health Services’ data indicate that harmful medication errors

Harmful Medication

represented 1.3 percent of the medication-related incidents from

Errors Were Consistent

the first quarter of 2007. This is consistent with national

With National Averages

averages, which indicate that harmful medication errors
represented 1.3 percent of total self-reported medication errors
for 2004 and 2005. This suggests that Jail Health Services’
patients are at no greater risk of harm due to medication errors
than patients in other healthcare settings. 7
Furthermore, we estimated that 1.9 percent of inmates receiving
medications in 2006 experienced a medication incident, based
on audit staff estimates of inmates receiving prescriptions 8 and
incidents reported by Jail Health Services staff. We compared
the 1.9 percent incident rate to a national benchmark on
medication errors reported in a 2001 study of 1,116 hospitals

7

While the Ombudsman’s complaint data show that a larger percentage (4.1 percent) of inmates was harmed by
medication incidents, the complaint data is not likely to reflect incidents that do not reach inmates, resulting in larger
percentages for other categories of incidents.
8
Information systems in place could not produce data identifying the number of inmates receiving medications or the
number of prescriptions received by inmates. The audit team analyzed sample data for 2006 to estimate this
information.

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by Pharmacotherapy. The study indicated that 5.1 percent of
patients experienced a medication error, which is more than
twice the incident rate we estimated for Jail Health Services. 9
It is important to point out that our analysis included data on Jail
Health Services’ medication incidents, which include some
incidents that are not actually considered errors based on the
nationally accepted criteria. An incident is when circumstances or
events occur that have the capacity to cause an error, but an
error does not actually occur (e.g., a nurse may drop a
medication, which then cannot be administered, but may obtain a
replacement in time to administer the dose without a delay to the
inmate). As a result, the 1.9 percent incident rate somewhat
overstates the percentage of inmates receiving medications who
experience an error. 10

2. WHAT ARE THE KEY CAUSES OF MEDICATION INCIDENTS AND ERRORS?
Individual Staff Error

Analysis of the Jail Health Services Medication Incident

Was the Primary

Reporting data indicated that individual staff error was reported

Reason for Medication

as the primary reason for medication errors. During the first

Errors

quarter of 2007, 81 percent of Jail Health Services’ reported
incidents were classified as individual staff errors as opposed to
systemic errors, which would reflect deficient policies,
procedures, and protocols.
We also examined data on where medication incidents occurred
in the medication process, as shown in Exhibit C below.

9

Pharmacotherapy 21(9):1023-1036, 2001. © 2001 Pharmacotherapy Publications
Incidents are self-reported by staff and may underestimate the true number of incidents. However, under-reporting
is likely to occur in all healthcare settings that use self-reported data on incidents and errors.
10

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EXHIBIT C
Medication Incidents Categorized by Process Step
Ordering
9%
Transcription
11%

Medication
Administration
46%
Dispensing
15%

Miscellaneous
19%
SOURCE: Jail Health Services, Medication Incident Report Data, First Quarter of 2007.

As shown in the exhibit above, incidents most commonly
occurred during medication administration (46 percent).
Medication administration issues typically involved medications
being administered late but also include incorrect or missed
dosages or medications administered to the wrong patient.
Transfers Between

One of the most frequently cited reasons for medication

Facilities Results in

administration errors involves transfers between facilities. Jail

Errors

Health Services’ medication administration processes did not
ensure that inmates’ medication orders were continued in a
timely manner following a transfer between facilities. One cause
for delays when an inmate transfers between facilities has been
Jail Health Services’ reliance on paper charts and records, which
must be physically located and moved between facilities.
Effective implementation of the electronic health record system
(EHR) will eliminate the need to physically locate an inmate’s

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chart. Providers, pharmacists, and nurses at both facilities will be
able to review any inmate’s chart from their computers.
Jail Health Services

In addition, as briefly discussed previously, JHS has begun filling

Implemented a Pilot

prescriptions on a 24-hour fill cycle at KCCF, and plans to

Program to Fill

expand the process to RJC. Under the previous process,

Prescriptions on a 24-

prescriptions were filled on a seven-day basis. If an inmate was

Hour Cycle

transferred a few days into the seven-day cycle, the remaining
dosages were transferred to the receiving facility once JHS
learned of the transfer (except narcotics and other controlled
substances, which were returned to the pharmacy inventory and
re-filled at the receiving facility). The inmate could experience
delays in receiving the prescribed medication in the new facility.
However, under the new process, single-dose medication orders
are re-filled every day. This means the pharmacy learns of a
transfer in a timelier manner. This should help ensure that a
transferred inmate will receive a dose without significant delay.
Further, these changes should reduce medication errors
associated with inter-facility transfers.
Miscellaneous incidents comprised the next largest category (19
percent). This category includes narcotic count discrepancies,
missing Medication Administration Records, unsecured narcotics,
and use of expired medications. Dispensing incidents (15
percent) include incorrect medications or dosages dispensed but
not administered, medications dispensed for the incorrect inmate
but not administered, delays in delivery from pharmacy to nursing
staff, and medications dispensed without an order. Transcription
incidents (11 percent) include duplicate or inaccurate Medication
Administration Records or missing orders. Ordering incidents
(9 percent) include confusing orders, an order written on the
incorrect chart, and incomplete orders.

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3. ARE MEDICATIONS, INCLUDING NARCOTICS AND OTHER CONTROLLED
SUBSTANCES, MISSING OR LOST?
Audit Identified

Jail Health Services’ medication process lacks the verification

Opportunities for

practices needed to identify lost or missing medications.

Medications to Be Lost

However, we identified eight opportunities within the current

or Diverted

operating model for medications to be lost with no controls, or
limited controls, to detect and monitor such events. These
opportunities are summarized in Exhibit D below.

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EXHIBIT D
Jail Health Services’ Current Pharmacy and Medication Administration Operating Model
Opportunities for Lost or Diverted
Medications

Medication Process Steps
Pharmacy purchases and stores medications
and manages inventory.

1) There is infrequent monitoring of inventory
and reconciliation of controlled substances only
to the medications that have been purchased,
dispensed, or returned.

Providers submit orders to pharmacy and
pharmacy reviews and approves orders.
Pharmacy prepares single-dose and keep-onperson medications and batches them in a bin
to be taken to the medication cart room.
Controlled substances are placed into the
locked narcotic cabinet in the medication cart
room by pharmacy staff and witnessed by
nursing staff. Both individuals count and sign a
document indicating the updated inventory
amounts. Pharmacy also prints and transmits
Medication Administration Records (MARs) for
each inmate receiving single-dose medications,
and places those with the medication carts.

2) Although the medication cart room is locked
with key access limited to licensed personnel,
many people have access throughout the day.

Nurses stock the medication carts with the
medications in the bin and take the medications
and Medication Administration Records to the
housing units for delivery. Urgent medications
are obtained from the Omnicell* machine when
the pharmacy is closed.

3) There are no inventory controls for stock of
medications maintained in the carts.
4) A nurse could lose or divert a medication and
indicate on the MAR that it was administered.
5) The Omnicell machine lacks controls to
prevent or detect medications that are removed
inappropriately.

After administering the medication, the nurse
documents that the single-dose medications
were administered on each inmate’s MAR. If a
non-controlled substance medication is not
administered on the pass, nurse keeps unused
doses to administer later during the shift,
returns doses to the cart for the next pass, or
deposits doses in pharmacy return bin to be
disposed of (if opened) or restocked (if
unopened). Controlled substances are disposed
of in specific labeled envelopes that are
returned directly to the pharmacy or kept in a
secure lockbox if the pharmacy is not open.

6) Pharmacy may not have knowledge of whose
orders were not administered since
documentation is not always attached to
returned medications as required by policies and
procedures.
7) No documentation is maintained to account
for non-controlled medications that are returned
to pharmacy for disposal, and no monitoring is in
place to detect inappropriate behavior.
8) No documentation is maintained to account
for non-controlled substance medications that
are returned to pharmacy for restocking, and no
monitoring is in place to detect inappropriate
behavior.

* Note: Omnicell is an information technology network system and physical cabinet that dispenses and houses
pharmaceuticals. Jail Health Services nurses “pull” medications from Omnicell when the pharmacy is closed (i.e., if
an inmate’s prescription has not yet been filled when it is time to administer medications).
SOURCE: Observation by audit team during site visits from April through August 2007 at the King County
Correctional Facility and the Regional Justice Center.

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The most significant opportunities identified for medications to be
lost or diverted involve “handoffs” between the pharmacy and
nursing staff. Significant opportunities to lose or divert
medications arise whenever the pharmacy relinquishes
responsibility for the medications to the nursing staff and vice
versa.
These handoffs should be the areas of focus for future process
improvements to increase control over medications at both RJC
and KCCF. Accountability for medication security should be
assigned and monitored at the appropriate staff level, and staff
access to medications should be minimized or controlled. Exhibit
E shows the two key handoffs in the current process that present
opportunities for medications to be lost or diverted.
EXHIBIT E
Identification of Key Handoffs Between Pharmacy and Nursing

Pharmacy:

Nursing:

Stock
Medications

Fill Orders

Fill Bins

Fill Carts &
Prepare for
Medication Pass

Restock

Conduct
Medication
Pass

Return
Unused
Medications

SOURCE: Observation by audit team during site visits from April through August 2007 at the King County
Correctional Facility and the Regional Justice Center.

The arrows represent the key handoffs between pharmacy and
nursing staff. Once pharmacy staff transfer the medication bins to
the medication cart room, they do not monitor or oversee nurses’
handling of medications. Similarly, once nurses return unused
medications to the pharmacy, there is no process in place to
ensure proper handling of the medications. No single position or
function is accountable for the entire process and no

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mechanisms are in place to cross-check inventory as it moves
from the pharmacy to the medication room or from the
medication carts back to pharmacy for restocking of unused
medications.
Our audit identified numerous deficiencies in the medication cart
rooms. The medication cart rooms are typically locked and can
only be opened by licensed clinical staff. However, the
medication cart rooms are poorly designed with medications
stored in open bins and are accessed by many people
throughout the day. Again, there is no way to verify that anyone
is actually taking advantage of these opportunities, because
there is no medication reconciliation process or inventory
management process in place to monitor and control behavior.
Additional Controls for

Additional controls for narcotics are in place, but these controls

Narcotics Are in Place

could be strengthened. Narcotics are stored in locked cabinets in

but Could Be Improved

the medication cart rooms, but the cabinet is typically left open
while nurses prepare their carts for a medication pass. Nurses
are also required to manually log each narcotic dose that is
removed from the cabinet and the log is reconciled at the end of
each shift. However, at KCCF narcotics are stored in a fraying
cardboard accordion file where they could easily fall out and be
lost.
Routine instances occur in which nurses are not able to
administer medications because the inmate has been released,
is in court, or refuses a medication. Processes are in place to
document this, but there are no safeguards to prohibit a nurse
from losing or taking the medication and noting in the Medication
Administration Record that it was actually administered to the
patient or returned to stock. Examples of potential safeguards,
ranging from low technology requirements to higher technology
requirements, include:

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ƒ

Periodic reviews of patient records against inmate location by
day and time to determine whether inmates were physically
present to receive a medication at the time of a specific
medication pass

ƒ

Establishing controls in the EHR system that prevent
recording that a medication has been administered if the
inmate has been released or is in court

ƒ

Bar-coding technology that requires nurses to scan the
barcode on the medication as well as the barcode on an
inmate’s wristband to document that the inmate was present
to receive the medication

In addition, as noted in the Board of Pharmacy reports and the
Ombudsman’s Office report, the current Omnicell machines are
poorly designed and provide an opportunity for diversion. When
the current machines are opened, non-controlled medications
inside are accessible and can be removed. Some processes are
in place to monitor the Omnicell inventory, but opportunity for
diversion still exists. When the machine is opened for a valid
medication order, other medications in the machine are also
accessible, and diversion of dosages of other medications may
not be caught through existing reconciliation procedures.
Jail Health Services has indicated that it is aware of the risks
associated with the Omnicell machines and is in the process of
acquiring a new automated storage and dispensing machine,
which will allow nurses to remove only the medications needed
for a specific inmate. (At the time of the audit, Jail Health
Services and the vendor were formalizing the lease contract for
the new machines.)

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Periodic Audits and

The risks discussed in this section could be reduced by

Enhanced Inventory

conducting periodic control audits to verify that medications not

Controls Would

administered (e.g., because an inmate was released or in court)

Improve Medication

are consistent with data on inmates’ locations during the

Accountability

medication pass. Procedures should also be established that
move Jail Health Services toward being able to account for all
medications at any point within the process. This includes
medications that are administered to the patient as documented
in the MAR and EHR, wasted due to contamination or expiration,
and returned unused to inventory. With the implementation of
EHR, Jail Health Services could consider ways to automate
inventory tracking.

RECOMMENDATION 1

Jail Health Services should conduct periodic audits and
strengthen inventory controls to enhance accountability for
medications ordered, dispensed, administered, disposed of, and
maintained in stock.

4. WHAT OTHER PROCESS IMPROVEMENTS CAN BE IMPLEMENTED TO INCREASE
ACCOUNTABILITY FOR MEDICATIONS AT KING COUNTY’S JAILS?
A number of additional process improvements are recommended
for Jail Health Services for implementation.
ƒ

Transfer responsibility for filling the carts with inmate
medications to pharmacy staff. This would eliminate the
need to transfer filled orders to the nurses to stock the carts.
Pharmacy technicians should be responsible for stocking the
carts, the nurses should be responsible for inspecting the
carts, and both will electronically sign off on the carts’
contents as each takes possession of the cart (i.e., nurses
would sign off at the beginning and end of each medication

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pass and pharmacy technicians would sign off upon return of
the cart to the pharmacy.)
ƒ

Expand the pilot process of filling medications on 24hour cycles rather than 7-day cycles. This process is
currently being piloted at KCCF and Jail Health Services
plans to expand it to include RJC. The 24-hour fill cycle
reduces the opportunity for losing medications or the need to
return medications when inmates are transferred or released
before their 7-day medication supply runs out.

ƒ

Reconfigure medication carts to increase accountability.
Medication carts should be prepared on a 24-hour cycle.
Each cart, similar to the current process, should hold
medications for a specific jail unit or group of units. However,
we recommend that drawers should be assigned to each
inmate on the unit who requires medication, and each drawer
should be segregated into three compartments, one for each
of the daily medication passes. Any medications not
administered to an inmate should remain in the inmate’s
compartment for that specific medication pass. This would
allow pharmacy staff to easily determine which pass an
inmate missed, verify drug usage against the MAR, and
improve inventory management practices. The nurse should
document on the MAR any dose that is not administered and
the reason. JHS has indicated interest in purchasing an
automated medication packaging system that would achieve
a similar level of accountability and could explore this idea
further for future implementation.

ƒ

Utilize portable electronic devices to document
medications administered. Jail Health Services indicated
that it plans to equip and train nurses to use portable devices
(such as laptop computers or hand-held devices) to capture

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medication administration data during the medication pass
and download the data into EHR upon return to the
medication room. This process change would give the
pharmacy access to the electronic MAR to verify drug usage,
monitor loss and wastage, and manage and reconcile
inventory.
Implementation of the process improvements described above
would strengthen the pharmacy’s control over and accountability
for medications issued to inmates. Using technology to capture
data about administration at the point of service will increase
control over medication dispensing and disposal and will reduce
the potential for loss or diversion. The combination of improved
processes and new technology should allow the pharmacy to
establish a medication reconciliation process to monitor all
medication inventories.
A benefit specific to the transferring of responsibility for filling the
medication carts to pharmacy staff is the reduction in time nurses
spend preparing for medication passes. Eliminating the need for
nurses to prepare the carts will increase the nurse staff time
available for patient care or may reduce the overall workload for
nurses. However, additional pharmacy staff resources may be
needed to take on the responsibility of filling the carts.
Consolidation of

We also identified a potential future improvement for

Pharmacy Operations

consideration, which is centralization of the KCCF and RJC

Could Be Considered

pharmacy operations and cart preparation activities. This would

for Future

concentrate JHS pharmacy expertise and resources in one place

Improvement

and eliminate the need to maintain two separate medication
inventories, thereby reducing the waste generated from unused
and expired medications. Critical medications could still be
stocked in the on-site storage and dispensing machines for afterhours needs at both facilities.

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However, additional pharmacy space may be needed given the
constraints of the current jail facilities, and secure transportation
capabilities would also be required to move medications from the
central pharmacy to the jails. Further analysis is needed to
comprehensively assess the costs and benefits of this option.

RECOMMENDATION 2

Jail Health Services should transfer responsibility for filling the
carts with inmate medications to pharmacy staff.

RECOMMENDATION 3

Jail Health Services should expand the pilot process of filling
medications on 24-hour cycles rather than 7-day cycles.

RECOMMENDATION 4

Jail Health Services should reconfigure medication carts to
increase accountability.

RECOMMENDATION 5

Jail Health Services should utilize portable electronic devices,
such as laptops or hand-held devices, to improve documentation
of the medication administration process.

RECOMMENDATION 6

Jail Health Services should conduct a feasibility analysis to
evaluate centralizing KCCF and RJC pharmacy operations.

5. HOW DO JAIL HEALTH SERVICES’ PRACTICES COMPARE TO OTHER JAILS?
Information on medication practices was collected from jails in
four other Washington counties: Clark, Pierce, Snohomish, and
Yakima. Two major differences between Jail Health Services and
the other jails are that none of the other jails operate on-site
pharmacies or provide the same breadth or depth of health
services as that provided by King County. This makes it difficult

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to compare Jail Health Services’ practices to other jail healthcare
operations.
Jail Health Services

Compared to the other county jails in Washington, Jail Health

Provides More Complex

Services provides a significantly more complex scope and range

Scope and Range of

of healthcare services. For example, none of the other jails

Services Than Other

operate infirmaries with 24-hour, daily coverage by skilled

Jails

nursing staff. Instead, inmates in need of medical care are
transported and treated by local hospitals. In addition, none of
the other jails provide the broad range of mental health services
and treatment units that King County does.
Most interestingly, none of the other in-state jails operate on-site
pharmacies. They either contract with private vendors or receive
pharmacy services through a local health center. This shifts to a
contractor the responsibility and risks associated with managing
medication inventory, stocking medication carts and dispensing
machines, and reconciling medications. This is an option that Jail
Health Services could consider the costs and benefits of when it
studies the feasibility of consolidating pharmacies.
Another notable theme highlighted during our survey was that the
primary mission of a jail is to provide 24-hour secure custody, not
to provide health services. This mission drives the facility’s
physical layout and operations in contrast to hospitals and other
institutions where health care is the primary mission. In a jail,
considerations of order, safety, and security take precedence
over other functions, and this can make managing medication
processes especially challenging.

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Healthcare and

These disparate objectives make it critical for correctional staff

Corrections Staff

and healthcare staff to coordinate activities. In the other

Interaction Impacts

Washington jails, healthcare operations are performed by the

Medication

correctional departments, which could promote greater

Administration Process

operational collaboration between custodial and healthcare staff.
During our site visits at KCCF and RJC, we observed that
interactions between Jail Health Services nursing staff and
Department of Adult and Juvenile Detention (DAJD) corrections
officers varied substantially, and these interactions influenced
how efficiently nurses were able to conduct medication passes.
Opportunities exist for Jail Health Services and DAJD to improve
collaboration during the medication administration process.

RECOMMENDATION 7

Jail Health Services should work with DAJD to modify their
Memorandum of Understanding to include regular joint reviews of
medication administration performance and to identify
opportunities for improvement. The joint reviews should
incorporate line staff involvement and/or input from both Jail
Health Services and DAJD.

6. WHAT QUALITY ASSURANCE ACTIVITIES DOES JAIL HEALTH SERVICES ENGAGE
IN AND ARE THESE ACTIVITIES CONSISTENT WITH BEST PRACTICES?
Healthcare organizations establish internal quality improvement
programs (QIP) to collect and analyze relevant performance data
and determine the risks associated with their practices. Our
review of Jail Health Services’ QIP, which is part of a broader
Public Health – Seattle and King County QIP, concluded that Jail
Health Services is developing and implementing an array of
activities that are consistent with healthcare industry best
practices for quality improvement.

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Jail Health Services

These practices should allow JHS to measure and document

Recently Established a

healthcare improvements, including improvements in medication

Pharmacy Committee

practices. Most notably in regard to our audit objectives, Jail

to Address Medication

Health Services has established a multi-disciplinary Pharmacy

Issues

Quality Assurance Committee that meets monthly to address
medication-related issues and has implemented a new process
that will allow management to more easily track and monitor
incidents by their severity and cause.
In Washington, a QIP is voluntary for healthcare organizations
other than hospitals. However, if an organization implements a
QIP, it can submit its plan to the Washington state Department of
Health for review and approval. State approval allows a
healthcare organization to exempt data collected and maintained
for QIP purposes from public disclosure. The exemption
encourages healthcare organizations and their staff to candidly
report and evaluate their practices.
Public Health cited confidentiality issues and its exemption from
publicly disclosing QIP-related information in its decision to
withhold some JHS information and studies that were needed to
more fully assess QIP practices. However, as noted above,
activities that are being implemented according to Jail Health
Services’ QIP plan are consistent with QIP best practices. Exhibit
F below summarizes the results of our comparison of Jail Health
Services’ QIP activities with best practices.

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EXHIBIT F
Comparison of Jail Health Services Quality Improvement Program Practice
to Best Practices
QIP Component
Best Practices
Jail Health Services (JHS) Practice
QIP Plan and
QIP plan and policies direct
Consistent with best practices and
Policies
organizations to evaluate
national accreditation standards
healthcare outcomes.
Plan is approved by
Consistent with best practices and
Washington Department of
state requirements
Health, providing legal
exemption from public
disclosure to encourage candid
evaluation of practices.
Data Collection
Relevant data is collected and
Consistent with best practices, as of
2007 – In 2007, JHS began tracking
and Analysis
categorized by cause and
medication incidents by cause and
severity.
severity.
Clinical experts from multiple
Consistent with best practices
disciplines are involved in
assessing the data.
Data are continuously
Inconclusive – JHS has only recently
monitored.
improved its tracking of relevant
medication incident data, but it plans to
review and trend the data quarterly.
Inconclusive – JHS did not provide
Measuring
Annual studies are conducted
studies conducted due to confidentiality
Impacts
to measure healthcare quality,
issues; however, we verified that
access, outcomes, and
NCCHC reviewed these studies during
processes, and all critical
the 2005 accreditation process and that
incidents should be reviewed.
they satisfied accreditation
requirements.
Performance measures are
Could be strengthened to better
adhere to best practices – Current
established to assess
performance measures focus on
outcomes.
process outputs rather than outcomes.
Source: King County Auditor’s Office best practices literature review on healthcare quality improvement programs.

As shown in Exhibit F above, Jail Health Services’ QIP plan,
policies, data collection, and planned data analysis activities are
consistent with best practices. Jail Health services’ QIP has been
approved by the state Department of Health and satisfied a
National Commission on Correctional Health Care (NCCHC)
accreditation review in 2005.

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New Medication

Consistent with best practices and practices recommended by

Incident Report

the jurisdictions we surveyed, Jail Health Services’ new

Process Provides

Medication Incident Report form process should provide useful

Useful Information on

information for management to assess medication processes and

Medication Errors

outcomes. The audit team, including a registered nurse from
Westcoast Consulting Group, observed the JHS Medical Director
and a nursing supervisor to verify their cause and severity
categorizations for a sample of Medication Incident Reports. We
concluded that the Medical Director and nursing supervisor used
consistent standards and methods for evaluating the incidents.
We encourage Jail Health Services to continue to utilize this
method for categorizing medication incidents and to ensure that
reviews of the medication incident data are conducted regularly
as planned.
However, Jail Health Services’ practices for measuring impacts
could be improved. Although Public Health did not provide
process and outcome studies due to confidentiality concerns, we
verified that NCCHC reviewed these studies during the 2005
accreditation process and that they satisfied accreditation
requirements. To demonstrate the results of their QIP studies,
Jail Health Services indicated that numerous improvements have
been made as a result of the QIP. In addition to the new process
for tracking and categorizing medication incidents, Jail Health
Services cited implementation of the Pharmacy Quality
Assurance Committee and development of the printed
Medication Administration Record as improvements that have
resulted from the QIP.

Performance Measures

Our best practices research also suggested that performance

Could Place Greater

measures could be strengthened to increase emphasis on

Emphasis on Outcomes

outcomes rather than process outputs. Jail Health Services has
identified numerous performance measures in its Strategic
Business Plan that primarily focus on outputs (e.g., number of

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treatments per day). We emphasize that publicly reportable
measures that focus on outcomes (e.g., number of adverse drug
events per 1,000 doses) are also important and would allow for
greater external monitoring of healthcare outcomes in the jails,
as well as the impact of quality improvement activities. Publicly
reportable performance measures would also help increase the
transparency and accountability of Jail Health Services’
healthcare program, particularly given the public disclosure
exemptions for information developed for QIP purposes.
We found through our research that measures and benchmarks
are not widely available for healthcare performance in
correctional settings. Still, some measures have been identified
by national accrediting organizations, such as the NCCHC and
the American Correctional Association (ACA). For example, ACA
requires correctional facilities to track the annual rate of
dispensing errors and the annual rate of errors in medication
administration. The expectation is that each facility will monitor its
rates over time to determine whether they are decreasing in
response to changes made in policies, procedures, staffing, or
training to improve performance.
Implementation of EHR in conjunction with improved processes
for reporting medication incidents provides an opportunity for Jail
Health Services to begin using performance data to better
manage medication processes and support its Quality
Improvement Program.

RECOMMENDATION 8

Jail Health Services should continue to utilize the new method of
categorizing medication incidents based on cause and severity,
and ensure that reviews of the medication incident data are
conducted regularly as planned.

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RECOMMENDATION 9

Pharmacy and Medication Administration Processes

Jail Health Services should identify key publicly reportable
performance measures, including outcome-based measures, for
medication administration and monitor these through the joint Jail
Health Services and DAJD reviews.

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3

NURSING AND PHARMACY STAFFING
This chapter discusses our review of Jail Health Services’ nurse
and pharmacy workload and staffing practices. In its November
2006 report, the Ombudsman’s Office described allegations from
Jail Health Services nurses and pharmacy staff that workloads
are increasing and shifts are frequently understaffed. In response
to these allegations, we evaluated how Jail Health Services
measures workload for its pharmacy and nursing shifts, how it
sets staffing levels to meet the demands of its workload, and
whether nursing shifts are frequently understaffed.
We found that although the current pharmacy staffing model is
based on an analysis of workload and productivity data, the
model was developed prior to significant changes in operations
and may not reflect the demands of the current workload.
Additionally, the current pharmacy staffing plan does not provide
coverage for employees who call in sick or take vacation.
Jail Health Services has begun to develop a nurse staffing model
that is based on workload and productivity; however, the limited
amount of electronic data accessible to JHS program staff has
made development of this kind of model difficult. As described in
Chapter 1, Jail Health Services is currently replacing its paperbased medical record system with electronic health records. With
the new system, program staff will be able to access electronic
information about the patients served and the productivity of
nurses. Once workload and productivity data are available, Jail
Health Services needs to evaluate the factors that impact its
staffing needs and link its nurse staffing plan to those factors.

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Additionally, through our review of staffing on a sample of almost
1,000 nursing shifts in 2006 and 2007, we identified a pattern of
shifts worked by fewer nurses than specified by the current plan,
particularly at the King County Correctional Facility (KCCF).
However, because JHS has not set nurse staffing levels using
workload and productivity data, we could not determine whether
a shift worked by fewer nurses than planned is actually
insufficiently staffed to meet the demands of the workload. In
order to improve staffing on nursing shifts, Jail Health Services
needs to ensure nursing schedules align with nurse staffing
plans; work to reduce vacancies and unscheduled leave; and
develop a staffing model that includes coverage for nurses on
leave.
In the following pages we answer many key questions about Jail
Health Services nurse and pharmacy workload and staffing.

PHARMACY AND NURSING WORKL0AD
1. IS MEDICATION-RELATED WORKLOAD INCREASING FOR NURSES AND
PHARMACY STAFF?
Although there is limited data available to document changes in
workload, data related to prescription volumes indicate that
pharmacy and medication administration workload has been
steadily increasing since 2003.
Pharmacy Volumes

Jail Health Services data on the number of prescriptions filled

Have Increased

annually indicates that the number of new prescriptions

Significantly Since

increased by over 26 percent in 2004 and by over 33 percent in

2003

2005. The increase in new prescription volume slowed to over 13
percent in 2006. As can be seen in Exhibit G, data on refill
prescriptions show an even steeper increase in volumes in 2005
and 2006; however, the 2005 decision to reduce the number of

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days covered by a prescription from 14 days to 7 days is also
reflected in the refill data.
EXHIBIT G
Jail Health Services Prescription Volumes, 2003–2006
p

Number of Prescriptions

120,000
100,000
New Prescriptions
80,000
60,000
Refill Prescriptions
40,000
20,000
0
2003

2004

2005

2006

Year

SOURCE: Jail Health Services

Percentage of Inmates

Jail Health Services staff reported to us that they suspect they

Treated by JHS

are also treating a higher percentage of inmates than they were

Appears to Be

five years ago. Since the information systems in place at the time

Increasing

of our audit did not allow Jail Health Services to track easily the
number of inmates served, we attempted to do so as part of this
project. We looked at inmate and prescription data for the first
two weeks of April between 2003 and 2007. We found that during
the same two-week period in April, the percentage of inmates
who received a prescription increased from 26 percent in 2003 to
over 36 percent in 2007.

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EXHIBIT H
Percentage of Inmates Receiving a Prescription, KCCF and RJC

% of Inmates Receiving
a Prescription

April 1–14, 2003–2007
50.0%
40.0%
30.0%
20.0%
10.0%
2003

2004

2005

2006

2007

Year

SOURCE: Auditor analysis of data from Jail Health Services

As can be seen in Exhibit I, the Average Daily Population in the
jails also increased between 2003 and 2006.
EXHIBIT I
Average Daily Population, KCCF and RJC
2003–2006

Average Daily Population

2750

2500

2250

2000

1750
2003

2004

2005

2006

Year

SOURCE: Department of Adult and Juvenile Detention

This means that as the average daily population was increasing,
the percentage of jail inmates receiving a prescription was also
increasing.

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Key Workload

Although prescription volume is an important measure of the

Measures Need to Be

workload of both pharmacy staff and nurses, there are other key

Developed and

measures of workload. For example, the volume of inmates

Monitored

through Intake, Transfer, and Release 11 ; the average number of
inmates in isolation; and the number of inmates with diseases
such as diabetes all indicate changes in Jail Health Services
workload. As the electronic health record system is implemented
and program staff can access detailed electronic data about
patients, services, and other demands on resources, Jail Health
Services needs to develop meaningful workload measures to
monitor changes in demands on their staff and the impacts of
changes in operating procedures and standards of care.
See Recommendation 11 related to developing and monitoring
key workload measures under Question 3.

PHARMACY STAFFING PLAN
2. IS THE PHARMACY STAFFING PLAN BASED ON ANALYSIS OF WORKLOAD AND
PRODUCTIVITY DATA?
The pharmacy staffing plan is based on an analysis of workload
and productivity data; however, the current plan is based on a
study completed prior to significant changes in operations.
In order to evaluate whether the current level of staff in the
pharmacies was sufficient, Jail Health Services (JHS) completed
a time and motion study of pharmacy operations in October
2006. Using staff estimates and also by timing actual pharmacy
procedures, JHS program staff calculated the average time
necessary to complete each task associated with filling a
prescription. Staff also attempted to calculate the average time
pharmacy staff spend on non-volume based tasks, such as

11

Jail Health Services nurses conduct an initial health screening on all inmates booked into the jails.

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meetings, quality improvement activities, and supervisory
responsibilities. The result is an estimate of the total number of
full-time equivalents (FTE) necessary to operate each pharmacy
each day of the week.
The 2006 model was the first staffing model completed for the
pharmacies. Prior to this model, pharmacy staff numbers were
set during the budget process and were based on historic levels
and changes in the inmate population.
Pharmacy Staffing

There are important limitations to the pharmacy staffing model.

Model Does Not

The first is that it assumes the pharmacists and technicians

Account for Staff Away

working in the pharmacy do not take any leave—the model does

From Work on Leave

not include any staff to cover employees on sick leave or
vacation. Additionally, the model assumes that all employees
working in the pharmacies are equally well trained. When
individuals are on leave or there are vacancies, Jail Health
Services covers its absences with overtime, temporary agency
pharmacy staff, or staff employed by other public health
pharmacies. These individuals may not be as well trained or as
efficient as JHS pharmacists and technicians. Additionally, they
usually do not perform the same duties as regular pharmacy
staff; for example, agency staff do not perform quality assurance
or other administrative tasks.

Model Has Not Been

Another important caveat to the current model is that it is based

Updated Since

on a time and motion study of processes that have changed and

Significant Changes in

are continuing to change. The recent procedural change to a 24-

Operations

hour fill process and the new electronic health record system are
already changing the workload of pharmacy technicians and
pharmacists. The remodeling of the KCCF pharmacy space will
further impact workload at this facility. As new systems and
processes are fully implemented, Jail Health Services will need

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to monitor workload changes closely and adjust staff as
necessary.
The program staff we met with were aware of both the inherent
weaknesses of a time and motion study and the need to
incorporate into the staffing plan coverage for leave. They have
already begun to update their FTE estimates to reflect the added
workload of the 24-hour fill process, and they are exploring
methods of ensuring they provide sufficient coverage for
employees on leave.
We recommend that Jail Health Services continue its update of
the pharmacy staffing model to ensure it reflects the demands of
the current workload. Additionally, we recommend Jail Health
Services develop a staffing model that incorporates relief for
employees on leave through an analysis of past leave use and
future staffing needs. As we will discuss further in Question 5,
Jail Health Services can develop a model that will help program
staff predict future leave use and project the most cost-effective
mix of staffing resources (full-time employees, overtime, and
temporary agency staff).

RECOMMENDATION 10

Jail Health Services should continue its update of the pharmacy
staffing model to ensure staffing estimates are based on current
processes and workload demands.
See Recommendation 13 at the end of Question 5 regarding the
need to factor employees on leave into the pharmacy staffing
model.

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NURSE STAFFING PLAN
3. IS THE JAIL HEALTH SERVICES NURSE STAFFING LEVEL BASED ON AN ANALYSIS
OF WORKLOAD AND PRODUCTIVITY DATA?
Nurse Staffing Level Is

The current Jail Health Services nurse staffing level is not based

Not Based on Analysis

on an analysis of workload and productivity data. Rather, the

of Workload and

level is based on a subjective estimate of the number of FTE

Productivity Data

necessary to complete the workload on each shift. In 2006, Jail
Health Services program staff began by documenting the
different types of nursing work on each shift at each facility.
These tasks were then grouped into “bodies of work,” such as
administering medications, working in the infirmary, and
conducting health assessments. Nurse supervisors estimated the
minimum level of nurses sufficient to meet the workload for each
body of work. The result is the current staffing plan, as
summarized in Exhibit J.

EXHIBIT J
Current Jail Health Services Nurse Staffing Matrix
Registered Nurse (RN) and Licensed Practical Nurse (LPN) Full-Time Equivalents
Monday-Friday

Saturday

Day

Eve

Night

Day

Eve

KCCF

15

15.5

5

15.5

RJC

10

5.5

2

5.5

Sunday
Night

Day

Eve

Night

12

5

12.5

12

5

5

2

5.5

5

2

Note: The numbers of nurses listed includes both RNs and LPNs.
SOURCE: Auditor analysis of data from Jail Health Services.

In order to support budget requests for staff and plan for future
increases in workload, Jail Health Services program staff have
also developed a number of threshold models that link nurse
staffing needs with the Average Daily Population (ADP) of
inmates in the jails. These models have also been based on
feedback from nursing supervisors.

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The advantage of the current approach is that it is grounded in
the experience of the nurse supervisors who work directly with
the nurses and see the impact of a growing workload and
changes in policies and procedures. The weakness of the
approach is that it is not based on an analysis of detailed
workload and productivity data. Additionally, as Jail Health
Services program staff and nurse supervisors explained to us,
inmate ADP is only one indicator of overall workload. Trends in
ADP may or may not correlate to trends in inmate health needs
and changing standards of care.
Program Staff Have

As we discussed earlier in this report, until the recent

Had Access to Limited

implementation of the electronic health record system, Jail Health

Data Related to Nurse

Services has had little data related to nursing workload. Program

Workload and

staff could not easily access detailed health information about

Productivity

their patients or the inmate population as a whole (e.g.,
percentage of inmates with mental health needs, diabetes, or
HIV). They could determine that prescription costs are
increasing, but they did not have the data necessary to answer
basic questions about whether they are treating a greater
number or percentage of inmates and whether the inmates they
treat require more care.

Electronic Health

Additionally, Jail Health Services had no data related to nurse

Records System Should

productivity. For example, because all patient treatments were

Improve Access to

recorded in paper charts and not tracked electronically, program

Data

staff and nurse supervisors could not determine the average
number of medications administered by nurses and how this
number varied by nurse, shift, inmate group, or facility. With the
implementation of the electronic health record system, data such
as this will be tracked automatically.
Jail Health Services will need to develop meaningful workload
and productivity measures as this kind of data becomes

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available. Analysis of these factors will allow management to
develop productivity goals and then link staffing levels to these
goals.
Jail Health Services management is aware of the need to link
staffing levels to workload indicators and productivity goals and is
working closely with the vendor of its electronic health records
system to ensure it gets the data necessary to strengthen staffing
practices.

RECOMMENDATION 11

Jail Health Services should develop a nurse staffing model that is
systematically linked to workload demands and productivity
goals. This model should incorporate the development and
monitoring of key workload and productivity measures and be
used for both staffing and scheduling analyses.

SCHEDULING
4. ARE NURSING SHIFTS FREQUENTLY UNDERSTAFFED IN THE JAILS?
Nursing Shifts Are

We analyzed the daily scheduling records for a sample of almost

Frequently Worked by

1,000 nursing shifts from July 2006 through June 2007, and we

Fewer Nurses Than

found that nursing shifts at both jails are frequently worked by

Planned

fewer nurses than specified in the current staffing plan. For the
shifts in our sample, one in five KCCF nursing shifts were worked
by at least 20 percent fewer nurses than planned. This means
that if the staffing plan stated that 10 nurses were needed on a
particular shift, that shift would have been worked by only eight
nurses. We found a lower rate of understaffing at RJC, where
one in ten of the shifts in our sample were worked by 20 percent
fewer nurses than planned.
We want to emphasize that because Jail Health Services does
not currently use workload and productivity data to set its nurse

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staffing levels, we could not determine with the data available
whether a shift worked by fewer nurses than planned is actually
insufficiently staffed to meet the demands of the workload.
Rather, our results indicate that Jail Health Services nursing
shifts are frequently staffed by fewer nurses than the current plan
specifies.
When Jail Health Services has nursing vacancies, when nurses
schedule vacations, or when a nurse is out on leave for a long
time (such as some leave protected under the Family and
Medical Leave Act), program staff try to schedule overtime or
temporary agency nurses to provide coverage. When this is not
possible, or when nurses call in sick only a few hours before their
shift, a shift is understaffed and the shift charge nurse attempts
to prioritize the workload among the available nurses.
The data we used for our analysis were records of which nurses
worked each day of the year. Using scheduling software, Jail
Health Services updates this data manually at the end of each
day for each facility. The records include information about when
Jail Health Services and temporary agency nurses worked; but
they include very limited data about why nurses were absent.
This means that we were not able to determine the relationship
between staffing levels and types of leave or vacancies, although
both influence Jail Health Services’ ability to cover nursing shifts.
Additionally, because the software that produced this data is
intended for scheduling purposes only, Jail Health Services
management can not easily manipulate the data to evaluate
current staffing trends, such as the amount of overtime worked or
the percentage of hours worked by temporary agency nurses. In
order to calculate this information, program staff would need to
manually transfer the scheduling data into another application.

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Some Shifts Are

Although we focused on identifying shifts on which too few

Worked by More

nurses worked in order to evaluate complaints regarding

Nurses Than Were

understaffing, we also identified a number of shifts on which too

Scheduled

many nurses worked. Overstaffing may allow nurses to catch up
on work not completed during understaffed shifts; however, it can
also indicate that resources are not being utilized efficiently or
cost-effectively. We did not quantify the frequency or degree of
overstaffing of nursing shifts; however, Recommendation 12 at
the end of this question addresses the issue of overstaffed shifts
as well as that of understaffed shifts.

Nurse Schedules Were

We identified three reasons for the under- and overstaffing

Not Updated to Match

issues we found in our sample. The first is that Jail Health

Staffing Plan

Services did not update nurse schedules at the same time that it
updated its staffing plan. Following the approach described in
Question 3, Jail Health Services program staff updated their
staffing plan in 2006 and again at the beginning of 2007.
However, they did not formally change nurse schedules to meet
current demands until August 2007. Instead of formally changing
nurses’ schedules, Jail Health Services program staff asked
nurses to alter their schedules informally, asked nurses to work
overtime, and brought in temporary agency staff when possible.
Additionally, program staff tried to ensure that vacancies were
filled by nurses who would work schedules that aligned better
with current staffing needs.
When we asked why it took so long to formally change the
nursing schedules, program staff explained that their attempts to
follow the process outlined in the Collective Bargaining
Agreement between Jail Health Services and the nurses’ union
led to delays in updating the schedules. Ultimately, the union
streamlined the process, and Jail Health Services is now
implementing new schedules that match the desired staffing
level.

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Nurse Staffing Plan

The second reason we identified for the fluctuations in staffing is

Does Not Include

that Jail Health Services has not fully incorporated into its staffing

Adequate Coverage for

plan the need to cover nurses on leave. Although Jail Health

Nurses on Leave

Services tries to cover expected absences (such as vacation or
maternity leave) by scheduling overtime or temporary agency
nurses, it has not developed a staffing plan that consistently
includes adequate relief for nurses absent from work. As we
describe in Question 5, it is possible to develop a model that
predicts future leave patterns using past leave use and leave
policies.

Nurse Vacancies

The third main factor impacting staffing levels at the jails is nurse

Impact Coverage

vacancies. Exhibit K shows vacancy rates in 2006 and 2007 for
all nursing positions in Jail Health Services and specifically for
RN positions.
EXHIBIT K
Vacancy Rates for Nursing Positions
1st
Quarter
2006

2nd
Quarter
2006

3rd
Quarter
2006

4th
Quarter
2006

1st
Quarter
2007

Jail Health Services
Nurse Vacancy Rate

8.4%

11.2%

4.2%

7.0%

15.9%

RJC RN Vacancy Rate

11.1%

11.1%

0.0%

0.0%

0.0%

KCCF RN Vacancy
Rate

11.6%

17.3%

8.7%

11.5%

29.1%

SOURCE: Auditor analysis of data from Jail Health Services.

The high vacancy rate for KCCF in 2007 reflects the creation of
four new RN positions. Without these new positions, the rate at
the end of the first quarter of 2007 would have been 21.5%.
From our research into the national nursing shortage, we found
that these numbers are not inconsistent with the national nursing
vacancy rate for RNs at hospitals. Studies conducted over the
past five years identify the current RN vacancy rate to be

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between 8.5 and 16.1 percent, and according to a study
prepared for the American Hospital Association in 2002, over one
in seven hospitals reported a severe RN vacancy rate of over 20
percent.
Nonetheless, high vacancy rates at KCCF can make scheduling
a sufficient number of nurses for each shift extremely difficult and
increase the need for temporary agency nurses. (We discuss the
higher costs and other drawbacks to relying on temporary nurses
in Question 7.) Jail Health Services has taken the following steps
in recent years to try to reduce the number of vacancies:
ƒ

Along with all of Public Health, implemented a new online job
posting and application system to improve the number and
quality of applications received and reduce the time between
application submission and interviews.

ƒ

Verified that nursing salaries are competitive with other area
employers.

ƒ

Hired a consultant to create a nursing recruitment plan and
brochure. Jail Health Services implemented the plan,
including utilizing targeted advertising and outreach methods.

Jail Health Services has also worked to improve working
conditions for nurses and to develop systems that allow nurses to
be more efficient. For example, both the electronic health record
system and the 24-hour prescription fill process should reduce
nursing workload.
Jail Health Services should continue its efforts both to recruit
nurses and to identify new processes that allow nurses to be
more efficient. As we explained above, when Jail Health Services
cannot find enough nurses to cover its vacancies, shifts are not
fully staffed. Program staff reported that staffing levels are further
reduced by nurses calling in sick, because it is extremely unlikely
to hire a temporary agency nurse on short notice as most

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agencies schedule their nurses weeks or months in advance. For
this reason, Jail Health Services does occasionally require
nurses to work mandatory overtime.

RECOMMENDATION 12

Jail Health Services should continue to ensure staff schedules
align with staffing plans and workload demands.
Additional recommendations to improve nurse scheduling are at
the end of Question 5.

5. HOW CAN JAIL HEALTH SERVICES IMPROVE ITS STAFF PLANNING TO ACHIEVE
THE DESIRED STAFFING LEVEL?
A Staffing Model Based

In order to improve staff planning, Jail Health Services could

on Leave Practices Can

develop a staffing model based on the minimum staffing level for

Predict the Most Cost

each shift, as determined by an analysis of workload and

Effective Mix of

productivity measures and current leave practices. This kind of

Staffing Resources

model uses historic leave use to project how many hours of
unscheduled leave a particular number of FTE are likely to take.
This approach can help management determine whether they
currently have a sufficient number of nurses to cover for nurses
on leave, and it can also be used to predict the most costeffective mix of full-time staff and temporary agency staff or
overtime.
This kind of model requires that Jail Health Services implement
two improvements to their current staffing practices:

ƒ

Accurately track all leave taken and hours worked by
employee. Currently, Jail Health Services does not have a
database that tracks hours worked and leave taken for each
employee. Additionally, Jail Health Services payroll data does
not include a record of leave without pay, which is a
significant amount of leave for Jail Health Services nurses.

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We estimated that the average Jail Health Services RN took
over 40 hours of leave without pay in 2006.

ƒ

Improve management of vacation leave. Neither the
Collective Bargaining Agreement between Jail Health
Services and its nurses nor internal policies specify the
number of nurses who can be away on vacation from each
shift. Although one nurse supervisor has developed a
guideline of allowing two nurses to be on vacation each day,
this is not a formal policy and has not been implemented
consistently. Additionally, this guideline does not specify how
many nurses can be on leave from each shift. This flexibility
has some benefits for the employee and the employer, but it
also makes it difficult for JHS to develop a staffing model that
will ensure coverage for nurses on vacation. A policy that
includes a specified number of leave slots on each shift
would allow management to formally factor vacations into
staff planning.

Further, to be most efficient, Jail Health Services should try to
minimize unscheduled absences. Unscheduled leave includes
any absence that was not planned and mostly consists of sick
leave. In 2006, the average full-time (1.0 FTE) RN took over one
full shift of unscheduled leave for every 10 shifts for which they
were scheduled. Although Jail Health Services cannot restrict
unscheduled leave, it should try to reduce it by developing
incentives that encourage nurses to save their leave and come to
work. The current collective bargaining agreement between
nurses and Jail Health Services provides nurses with the
opportunity to convert 16 hours of accrued sick leave to two
vacation days if they use fewer than 33 hours of sick leave over
the calendar year. One problem with this policy is that it is not an
effective incentive for nurses to save their sick leave. Nurses can
either use their sick leave as unscheduled leave whenever they

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wish, or they can convert it to vacation leave and take it when it
will be approved by management. Converting the leave into
vacation actually reduces the employee’s flexibility in when they
can use it.
Alternatives to this policy might include allowing employees to
cash out accrued sick leave, rewarding employees who save
their leave with something other than additional leave, or
restricting a nurse’s ability to earn overtime in periods that the
nurse also takes unscheduled leave. Jail Health Services will
have to weigh their options carefully on this issue to encourage
nurses to minimize unscheduled absences without hurting
morale. This is especially important in the context of the current
nursing shortage.

RECOMMENDATION 13

Jail Health Services should incorporate the need to cover
employees on leave into its staffing plans. Jail Health Services
should use statistical analyses to assess its current staffing level
and to model the most cost-effective mix of full-time staff,
overtime, and temporary agency staff.

RECOMMENDATION 14

Jail Health Services should develop a method to track all hours
of employee work and leave.

RECOMMENDATION 15

Jail Health Services should improve management of vacation
leave by specifying the maximum number of staff who can take
vacation from each shift. Additionally, Jail Health Services should
consider improving current leave policies to create an incentive
for employees to save their sick leave.

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STAFFING OPTIONS
6. WHAT ARE THE AVERAGE HOURLY COSTS OF THE NURSES WHO STAFF THE
JAILS?
We found that the average cost per hour worked of a temporary
agency nurse is generally higher than that of a Jail Health
Services (JHS) nurse, that the cost per hour worked of a parttime JHS nurse is about four percent higher than that of a fulltime JHS nurse, and that the hourly cost of a JHS nurse working
overtime is between 8 and 15 percent more than for a JHS nurse
working a regular shift.
We analyzed the average hourly rate, cost of benefits, hours
worked, and hours of leave for all Jail Health Services nurses
and calculated the average cost per hour worked for regular fulltime (1.0 FTE) RNs, regular part-time (0.8 FTE) RNs, regular
RNs working overtime, and temporary agency RNs working three
different shifts in the jails. We looked at three different shifts,
because nurses earn between $2.50 and $7.75 more for working
in the evening or on the weekend than they do for working a
regular day shift during the week. We focused on RNs in this
analysis because they make up the majority of Jail Health
Services regular employees and the majority of agency staff. The
results of our analysis can be seen in Exhibit L.

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EXHIBIT L
2006 Average Cost per Hour Worked of Jail Health Services Registered Nurses (RN)
Day Shift,
Monday-Friday

Night Shift,
Monday-Friday

Night Shift,
Weekend

1.0 FTE Jail Health Services RN

$51.71

$56.47

$61.55

0.8 FTE Jail Health Services RN

$53.83

$58.64

$63.77

Jail Health Services RN working overtime

$58.16

$64.39

$71.03

Agency RN who works 1,000 hours in 12 months

$64.72

$64.72

$64.72

Note: Nurses earn a shift differential in addition to their regular rate of pay for each hour they work during an
evening, night, or weekend shift. The evening differential is $2.50 per hour, the night differential is $3.75 per hour,
and the weekend differential is $4.00 per hour. Nurses can earn both a shift and a weekend differential for the same
shift. This means that a nurse who works a night shift on the weekend would earn $7.75 per hour in addition to his
or her regular hourly rate.
SOURCE: Auditor analysis of Jail Health Services payroll data.

In our analysis of 2006 nurse staffing costs, we found that the
average hourly wage for RNs was $35.02. When we added the
cost of benefits and the cost of paying nurses for the time they
are away on leave, we found that nurses who worked five day
shifts during the work week (1.0 FTE) cost $51.71 per hour
worked and nurses who worked four day shifts per week (0.8
FTE) cost $53.83 per hour worked. The amounts increased for
the night and weekend shifts, but they remained within four
percent of each other.
It was surprising to us that the final cost per hour was so similar
for both groups. We had expected to see a greater difference in
cost because the department pays for full medical and dental
benefits for 0.8 FTE nurses while those nurses work fewer
annual hours. However, in 2006, the part-time (0.8 FTE) nurses
took significantly fewer hours of unscheduled leave, and so the
county did not pay these nurses for as much time away from
work as they did full-time nurses. The results of this analysis
would change if leave use changed.

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Exhibit L also shows that the cost of paying a regular Jail Health
Services RN to work overtime costs Jail Health Services between
8 and 15 percent over the regular hourly rate. Although nurses
working overtime are paid at the rate of time and one half the
nurse’s regular hourly wage, the county does not have to pay full
benefits and cover the cost of leave in addition to the wage.
Thus, the full cost of paying a nurse to work overtime is
significantly less than one and one half times the actual hourly
cost per hour worked.
We found that the average cost of a temporary agency RN is
almost $65 per hour worked if that nurse works 1,000 hours for
the jails in a 12-month period. Under current law, temporary
employees can work for the county up to 1,100 hours in a twelvemonth period without receiving benefits. Jail Health Services
stops using an agency nurse after the nurse works 1,000 hours
in order to ensure that temporary nurses do not exceed the hour
limit. However, Jail Health Services program staff reported to us
that many agency nurses do not work a full 1,000 hours at the
jails. As the number of hours worked by an agency nurse
decreases, the cost per hour worked increases. This is because
Jail Health Services has to pay for an orientation period for each
agency nurse regardless of how long the nurse works at the jails.
For example, if a temporary agency nurse works in the jails for
only 40 hours, the cost per hour worked increases to $83.14.
Although we identified several agency nurses who worked at the
jails for less than one week, the average agency RN worked at
Jail Health Services for about 380 hours in 2006. The cost of an
agency RN who works the average number of hours is
approximately $66 per hour worked.

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7. WHAT ARE THE IMPACTS OF HAVING AGENCY NURSES WORKING IN THE JAILS?
As can be seen in Exhibit M below, temporary agency nurses
worked a significant portion of total Jail Health Services nursing
hours in 2005 and 2006.
EXHIBIT M
JHS Nursing Hours, 2005 - 2006
160000

Agency LPN
Agency LPN

140000
JHS LPN

Number of Hours

120000

JHS LPN
Agency RN

100000
Agency RN

80000
60000
40000

JHS RN

JHS RN

2005

2006

20000
0

SOURCE: Auditor analysis of data from Jail Health Services

Temporary Agency

In 2006, Jail Health Services paid temporary agency RNs almost

Nurses Work a

$1,170,000 to work over 18,000 hours in the jails. These nurses

Significant Portion of

covered vacancies and shifts left open by JHS nurses who were

Total Nursing Shifts

out sick or on vacation.
The option of using agency nurses provides Jail Health Services
with valuable flexibility in covering vacancies and absences.
Additionally, agency nurses can provide additional coverage
during short term increases in workload, such as the recent
transition to the electronic health records system. However, as
can be seen in Exhibit L under Question 6, the average agency

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nurse working a day shift costs the county over 10 dollars per
hour more than a regular full-time nurse. If all agency nurses
worked the full number of hours allowed under the law, in 2006
JHS would have paid over $100,000 more for agency RNs who
worked day shifts than they would have paid full-time nurses to
cover these shifts.
Additionally, Jail Health Services management indicated that
because some agency nurses work only periodically or for just a
few weeks, many are trained in only one area of the jail and may
be limited in the type of work they can perform. For example,
some agency nurses are trained only to administer medications
or to work in the infirmary, but not to do both. Finally, program
staff reported to us that because temporary agency nurses are
limited in the number of hours they can work for the county, Jail
Health Services spends a significant amount of time recruiting
and orienting new temporary nurses.
Jail Health Services management is aware of the issues with
using agency nurses and is actively working to reduce its
dependence on them. Recent steps taken by Jail Health Services
in this area include reducing funds for agency staff in order to
create more full-time nursing positions, increasing efforts to
reduce vacancies (as described in greater detail in Question 4),
and filling open positions with nurses willing to work full-time (1.0
FTE rather than 0.8 FTE). In addition, new systems and
processes at Jail Health Services, such as the electronic health
records system and the 24-hour prescription fill, should help
nurses be more efficient.
Steps such as these, in addition to implementation of our
recommendations to improve staff planning and scheduling,
should help Jail Health Services use its staffing resources more
efficiently and more cost-effectively.

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APPENDICES

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APPENDIX 1
2004 – 2006 MEDICATION-RELATED INMATE COMPLAINTS TO
KING COUNTY OMBUDSMAN’S OFFICE

No Error

Error but
No Harm

Error that
May Have
Contributed
to or
Caused
Harm

Error that
Caused
Death
Total

Description*
A. Circumstances occurred that
have capacity to cause error but no
error occurred
B. Error occurred but did not reach
patient
C. Error reached patient but did
not cause harm
D. Error reached patient and
required monitoring to confirm that
it resulted in no harm and/or
required intervention to preclude
harm
E. Error may have contributed to
or resulted in temporary harm and
required intervention
F. Error may have contributed to
or resulted in temporary harm and
required hospitalization
G. Error may have contributed to
or resulted in permanent harm
H. Error occurred requiring
intervention to sustain life
I. An error occurred that may have
contributed to or resulted in the
patient’s death

Percent
by
Category

2004

2005

2006

3-Year
Total

10

24

19

53

31.0%

-

-

-

-

-

11

61

28

100

58.5%

1

3

7

11

6.4%

-

1

-

1

0.6%

1

1

2

4

2.3%

1

-

-

1

0.6%

-

1

-

1

0.6%

-

-

-

-

-

24

91

56

171

100%

* Note: Index based on Medication Errors Reporting Methodology by the United States Pharmacopoeia
Medication Error Reporting Program.
Source: King County Ombudsman’s Office complaint logs and Westcoast Consulting Group analysis. The
Ombudsman’s Office report identified 192 medication-related complaints from January 2004 through
November 2006. Consultants assessed only 171 of these complaints, excluding complaints in which it
appeared that the inmate had not yet seen a provider or been prescribed a medication or for which the logs
requested from the Ombudsman’s Office included only general information about the complaint. The
Ombudsman’s Office maintains more detailed records of complaints in case notes, but those were not
reviewed as part of this analysis.

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APPENDIX 2
JAIL HEALTH SERVICES MEDICATION INCIDENT REPORTS

No Error

Error but No
Harm

Error that
May Have
Contributed
to or
Caused
Harm

Error that
Caused
Death

Description
A. Circumstances occurred
that have capacity to cause
error but no error occurred
B. Error occurred but did not
reach patient
C. Error reached patient but
did not cause harm
D. Error reached patient and
required monitoring to confirm
that it resulted in no harm
and/or required intervention to
preclude harm
E. Error may have
contributed to or resulted in
temporary harm and required
intervention
F. Error may have contributed
to or resulted in temporary
harm and required
hospitalization
G. Error may have
contributed to or resulted in
permanent harm
H. Error occurred requiring
intervention to sustain life
I. An error occurred that may
have contributed to or resulted
in the patient’s death

10-Percent
Sample
2006*

Percent
by
Category
2006

Quarter 1
Actuals
2007

Percent
by
Category
2007

7

10.4%

28

17.7%

36

53.7%

18

11.4%

17

25.4%

91

57.6%

6

9.0%

19

12.0%

0

0.0%

2

1.3%

0

0.0%

0

0.0%

0

0.0%

0

0.0%

0

0.0%

0

0.0%

0

0.0%

0

0.0%

66

100%

158

100%

Total

* Note: The audit team, including a registered nurse from Westcoast Consulting Group, observed and
validated Jail Health Services’ process for categorizing select incidents for the 2006 sample.
Source: Medication Incident Reports prepared by Jail Health Services.

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LIST OF RECOMMENDATIONS & IMPLEMENTATION SCHEDULE
Recommendation 1: Jail Health Services should conduct periodic audits and strengthen
inventory controls to enhance accountability for medications ordered, dispensed, administered,
disposed of, and maintained in stock.
Implementation Date: Audits will begin in 2008
Estimate of Impact: Enhanced controls will improve accountability for medications and
reduce the likelihood of medications being lost or diverted.
Recommendation 2: Jail Health Services should transfer responsibility for filling the carts with
inmate medications to pharmacy staff.
Implementation Date: Implemented as of September 10, 2007
Estimate of Impact: Transferring responsibility for filling the carts to pharmacy staff will
create a single point of accountability for the medications at all points in the medication
dispensing and administration processes. The pharmacy will be accountable for
medications until nurses take possession of the medication carts to conduct their
medication passes. This will also increase efficiency by eliminating the time nurses
spend on stocking the carts and shifting this responsibility to pharmacy technicians.
Recommendation 3: Jail Health Services should expand the pilot process of filling medications
on 24-hour cycles rather than 7-day cycles.
Implementation Date: Implemented as of September 10, 2007
Estimate of Impact: This will improve medication process efficiency and effectiveness
when inmates are transferred between facilities. Efficiency will be improved because
less staff time will be devoted to researching transferred inmates’ medication
requirements. Effectiveness will be improved because inmates should experience fewer
delays in receiving medications once they have been transferred.
Recommendation 4: Jail Health Services should reconfigure medication carts to increase
accountability.
Implementation Date: Implemented as of September 10, 2007
Estimate of Impact: The recommended cart configuration would allow the pharmacy to
easily identify which inmates did not take their medications and during which pass. This
strengthens medication administration process accountability and may allow for better
patient care by enhancing pharmacists’ ability to identify patients who do not take their
medications are prescribed.

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LIST OF RECOMMENDATIONS & IMPLEMENTATION SCHEDULE (Continued)
Recommendation 5: Jail Health Services should utilize portable electronic devices, such as
laptops or hand-held devices, to improve documentation of the medication administration
process.
Implementation Date: Feasibility analysis to be completed in 2008
Estimate of Impact: Use of portable electronic devices would allow data from each
medication pass to be efficiently uploaded into the electronic health record system,
thereby enabling better oversight by the pharmacy.
Recommendation 6: Jail Health Services should conduct a feasibility analysis to evaluate
centralizing KCCF and RJC pharmacy operations.
Implementation Date: Feasibility analysis to be undertaken in early 2009
Estimate of Impact: A feasibility analysis would provide valuable information on the
potential efficiencies and process improvements of centralization of the pharmacies, as
well as information on the potential costs or drawbacks.
Recommendation 7: Jail Health Services should work with DAJD to modify their Memorandum
of Understanding to include regular joint reviews of medication administration performance and
to identify opportunities for improvement. The joint reviews should incorporate line staff
involvement and/or input from both Jail Health Services and DAJD.
Implementation Date: December 31, 2007
Estimate of Impact: Joint reviews will enable line staff from Jail Health Services and the
Department of Adult and Juvenile Detention to discuss issues or concerns related to
medication administration. This will allow staff from both agencies to collaborate on
identifying solutions to increase medication administration process efficiency and
effectiveness.
Recommendation 8: Jail Health Services should continue to utilize the new method of
categorizing medication incidents based on cause and severity, and ensure that reviews of the
medication incident data are conducted regularly as planned.
Implementation Date: Implemented in January 2007 and currently ongoing
Estimate of Impact: Continued use of the new medication incident reporting process
will enable Jail Health Services to track medication incidents and improve the
accountability and effectiveness of its medication practices.
Recommendation 9: Jail Health Services should identify key publicly reportable performance
measures, including outcome-based measures, for medication administration and monitor these
through the joint Jail Health Services and DAJD reviews.
Implementation Date: June 30, 2008
Estimate of Impact: Publicly reportable performance measures will increase
transparency and accountability of Jail Health Services’ medication practices.

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LIST OF RECOMMENDATIONS & IMPLEMENTATION SCHEDULE (Continued)
Recommendation 10: Jail Health Services should continue its update of the pharmacy staffing
model to ensure staffing estimates are based on current processes and workload demands.
Implementation Date: December 31, 2008.
Estimate of Impact: Updating the pharmacy staffing model with current workload and
productivity data will ensure that Jail Health Services pharmacies are staffed at the level
necessary to meet the demands of the workload.
Recommendation 11: Jail Health Services should develop a nurse staffing model that is
systematically linked to workload demands and productivity goals. This model should
incorporate the development and monitoring of key workload and productivity measures and be
used for both staffing and scheduling analyses.
Implementation Date: In process
Estimate of Impact: Developing a nurse staffing model that is linked to workload
demands and productivity goals will allow Jail Health Services to ensure staffing levels
are sufficient to meet the demands of the workload and also adjust staffing levels as
workload changes.
Recommendation 12: Jail Health Services should continue to ensure staff schedules align with
staffing plans and workload demands.
Implementation Date: Ongoing
Estimate of Impact: Once the staffing plan is linked to workload demands and
productivity goals (Recommendation 11), aligning staff schedules with the staffing plan
will ensure nursing shifts are staffed at the level that is appropriate for the workload. This
will reduce both understaffing and overstaffing on nursing shifts.
Recommendation 13: Jail Health Services should incorporate the need to cover employees on
leave into its staffing plans. Jail Health Services should use statistical analyses to assess its
current staffing level and to model the most cost-effective mix of full-time staff, overtime, and
temporary agency staff.
Implementation Date: December 31, 2008
Estimate of Impact: Improved planning for employees on leave will reduce
understaffing on shifts when employees call in sick. Additionally, an assessment of
current leave trends and the costs of various staffing options can help JHS budget for
the cost of covering employees on leave and determine the most cost-effective mix of
staffing resources.
Recommendation 14: Jail Health Services should develop a method to track all hours of
employee work and leave.
Implementation Date: Subject to Peoplesoft installation

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LIST OF RECOMMENDATIONS & IMPLEMENTATION SCHEDULE (Continued)
Estimate of Impact: Accurately tracking all hours of employee work and leave is an
essential step to developing a model that can be used to predict future leave use.
Recommendation 15: Jail Health Services should improve management of vacation leave by
specifying the maximum number of staff who can take vacation from each shift. Additionally, Jail
Health Services should consider improving current leave policies to create an incentive for
employees to save their sick leave.
Implementation Date: Vacation guidelines will be updated January 1, 2008. Leave
policy changes will be subject to collective bargaining negotiations.
Estimate of Impact: Determining the maximum number of employees who can take
vacation from each shift is an essential step in planning for employee leave. Reducing
sick leave use will result in a decrease in the need for overtime or temporary agency
staff and will lead to cost savings.

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EXECUTIVE RESPONSE

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EXECUTIVE RESPONSE (Continued)

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