KeePosted - ICHP

Professional Affairs
Medication Safety Pearl : Tools to Prospectively
Identify Medication Safety Initiatives
by Sandra M Salverson, PharmD, BCPS
Introduction
A strategic plan for medication safety
is crucial to the safety of patients
and the success of a medical center.
ASHP has challenged all of us to
increase the extent to which pharmacy
departments in health systems
have a significant role in improving
the safety of medication use in the
2015 Initiative. The desire is to have
90% of health systems supporting an
organizational program, with appropriate
pharmacy involvement, that
achieves significant annual, documented
improvement in the safety
of all steps in medication use. 1
The Division of Professional Affairs
is committed to assist the ICHP
membership in achieving this goal
through sharing significant practices
that can help improve medication
use at their institutions. The topic
of safe and appropriate medication
use has the potential to affect
us all personally, whether we are
healthcare professionals, patients
or the family members of patients.
We encourage all practitioners and
institutions around the state to submit
their safety or quality initiatives
as a medication safety pearl to
the Division. Topics could include,
but are not limited to: high alert
medications, IV room/sterile preparation
safety, meaningful metrics,
computerized physician order entry
(CPOE), bedside bar-coding, smart
pumps, automated dispensing cabinets,
checklists, human factors, or
changes in dispensing or pharmacist
monitoring practices due to an
adverse event. Our hope is to identify
specific, practical practices that
are addressing important safety and
medication use issues at the frontline
of care across the state and
present these to the ICHP members
through KeePosted articles and presentations
at the Annual and Spring
meetings.
Tools to Prospectively Identify
Medication Safety Initiatives
A key piece of safety culture is
understanding human and system
failure. The science of measuring
patient safety is immature and
institutions need to find a balance
between measures that are scientifically
sound, affordable, usable and
easily applied. 2 Leaders in patient
safety suggest grouping measures
in three primary buckets: harm,
interventions to reduce harm and
organizational learning. While
harm and interventions to reduce
harm are institution specific measures,
organizational learning is not
limited to learning from within.
Organizations can learn retrospectively
from their own significant
experiences (actual errors or near
misses) and prospectively from near
misses, critical “close calls”, and
adverse events occurring outside of
an organization. The goal in growing
safety culture is to move perceptions
away from “it can’t happen
here” to “how can we prevent this
from happening here”. The purpose
of this pearl is to share external
resources to aid in prospective
organizational learning as a part of
improving medication safety culture.
Institute of Safe Medication
Practices (ISMP) Quarterly
Action Agenda 3
The ISMP publishes a quarterly
action agenda in its newsletter
that summarizes adverse events
or critical near misses resulting
from medication errors. It is an
excellent source to identify potential
organization risk and provides
recommendations on how institutions
can prevent this from happening
in their own organization.
ISMP recommendations focus on
both system-design and human factors.
The agendas summarize ten
to fifteen problems each quarter.
The quarterly action agenda is in a
ready to use format that facilitates
documentation and communication
within an institution/system.
The tool may be downloaded free
from their web site (http://www.
ismp.org/Newsletters/acutecare/
actionagendas.asp). The quarterly
action agenda can easily stimulate
a variety of performance improvement
projects. For those institutions
in the early stages of developing
their medication safety culture,
consider picking one problem each
quarter and performing a proactive
assessment within your institution.
20 July 2011 | KeePosted | www.ichpnet.org