• Eliminate the use of infusion pumps without free-flow protection. Organizations that continue to utilize infusion pumps that do not have set-based free-flow protection should develop plans for purchasing free-flow protected devices. Pumps that allow free flow to occur represent a significant risk to patient safety and a liability to the hospital. Until such pumps can be eliminated from an organization, caregivers should be educated on the dangers of free flow. This education should include all employees who could come into direct contact with the patient (e.g., patient transport staff, radiology technicians).
• Prepare for the implementation of computerized prescriber order entry (CPOE).
CPOE systems have been promoted to address many of the ordering problems that contribute to medication errors (e.g., illegible orders, incomplete orders, and the use of dangerous abbreviations). Such systems can also reduce the need for verbal orders, because access to a terminal, rather than to the patient chart, allows the physician to place an order. In addition, orders can be checked for dosage, interactions, and duplication, and the physician can be notified of these problems at the time of prescribing. Some CPOE systems allow for expert rules that can improve medication prescribing. Another factor driving hospitals to investigate CPOE systems is pressure from outside groups (e.g., the Leapfrog Group) that steer patients to organizations with CPOE systems in place.
Several tools were developed to assist each hospital in the implementation process for the goals. The ‘toolkit” provided to each organization consisted of a medication-safety binder, a series of “10 safe practices” campaign posters, along with a plan for rolling out and displaying the posters in the institution, and a practical guide for CPOE.
The medication-safety binder was designed as a ‘how-to” manual, containing safety checklists for high-alert drugs and infusion pumps, medication safety pledges for patients, sample policies and job descriptions, recommendations for implementing the steps necessary to achieve the goals, and a description of the successful implementation of each goal. The multicolor safe-practices posters focus on several of the action goals (e.g., safety innovation, floor-stock guidelines, essential patient information, dangerous abbreviations, high-alert medications, verbal orders, and the use of triggers to capture adverse drug events). Each of these posters supports the information found in the binder for the corresponding action goal. The posters can be combined with internal education programs and in-services to allow each institution to systematically address the key issues surrounding each goal. A separate publication, “Computerized Prescriber Order-Entry Systems – A Practical Guide,” provides detailed planning guidance and acquisition tools to assist the hospitals as they move toward a CPOE system environment. The guide also includes comparison charts of available systems, a request-for-proposal template, and a proposal analysis matrix.
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The RMSPH also included a pre- and post-survey tool for each hospital. A catalog of questions was developed, focusing on the 16 action goals. Selected questions were incorporated into different versions of the survey tool, which were then distributed to employees in 18 different clinical and management functions throughout the organization. This survey was distributed prior to the initiation of the program to determine the employees’ perception of the organization’s medication-safety practices around the action goals. The same survey will be redistributed to employees with the same job classifications at the completion of the program and the aggregate data from the two surveys will be analyzed to determine whether the perception has changed as a result of the program.
A series of meetings was held to introduce the program. The first meeting was designed to introduce the program to members of the hospital leadership. Invitations were extended to representatives from the governing board, senior management, and medical staff leadership. At this meeting, the program was described and the point was made that this program would dovetail with any other patient-safety initiatives in which the hospital was participating. Two additional meetings were held for the risk managers and the directors of pharmacy from each organization.
After these kick-off meetings, the patient-safety officer for each organization was invited to two full-day training sessions. At these sessions, presenters from ISMP and ECRI described the program and reviewed the 16 action goals. The safe practice campaigns posters, the medication-safety binders and tools created to assist in the implementation were distributed to the safety officers.
Throughout the program, patient-safety officers were invited to participate in informal workshops, which focused on the four key areas. These workshops provided a forum for describing obstacles that were being encountered, and for sharing ideas and successes that had been realized. Several different individuals, including pharmacy directors, patient-safety officers, risk managers, and performance improvement coordinators, attended these workshops.
On-site Survey: Looking Ahead
An integral part of the RMSPH’s plan for the future is a one-day on-site review that will be performed by a team of two individuals, one each from ISMP and ECRI. The purpose of the site visit is to assess the progress that each organization has made with the implementation of the program. This on-site review will consist of interviews with several key individuals in the organization, a review of selected documents and policies, and direct observations of the various aspects of the medication-use process. After the on-site visit, each organization will receive a written action plan providing recommendations to assist in the implementation of the action goals.
The two landmark IOM reports (“To Err is Human: Building a Safer Health System” and “Crossing the Quality Chasm: A New Health System for the 21st Century”) have focused a bright spotlight on patient safety and its connection to quality of care. Multiple national organizations and purchasing alliances have developed programs with curricula heavily focused on patient and medication safety. The new JCAHO standards published in July 2001 address patient safety, as well as the reduction and disclosure of medical errors. The RMSPH was designed to coordinate with these efforts rather than duplicating them. Institutions that implement the 16 action goals will be satisfying several of the JCAHO standards and moving toward compliance with others.
The toolkit for the RMSPH is available to hospitals outside the greater Philadelphia area. For more information about the RMSPH.