After the Institute of Medicine (IOM) released its landmark report, ‘To Err is Human: Building a Safer Health System,” the Delaware Valley Hospital Council (DVHC) began to consider programs that could enhance patient safety and quality of care in its member organizations. After deliberation, the DVHC decided to embark on a program that would assist member institutions by focusing on one critical aspect of patient safety—reducing medication errors. Through its charitable foundation affiliate, the Health Care Improvement Foundation, the DVHC partnered with two local organizations, the Institute for Safe Medication Practices (ISMP) and ECRI. This partnership has resulted in a unique and exceptional combination of access, knowledge, and technical assistance. Working collaboratively, the three organizations developed the Regional Medication Safety Program for Hospitals (RMSPH). Although many institutions were already working individually to enhance the quality of their services and improve patient safety, it was felt that the hospitals in the Delaware Valley region would benefit from this region-wide coordinated campaign.
The program, designed for implementation over a two-year period, involves all stakeholders within each hospital, including the governing board, senior management, medical staff, and employees; and it solicits participation from patients and the community. The RMSPH supports the systematic implementation of sixteen medication-safety goals, or ‘action goals,” as part of a strategic and cohesive program. Because the P&T committee oversees the medication-use process in most institutions, consideration of these goals (along with subsequent implementation) will fall under the purview of the P&T committee. These 16 goals represent four distinct areas: institutional culture, infrastructure, clinical practice, and technology. The goals are listed below, with a brief description of the implications of each for participating hospitals.
• The organization should commitment to a culture of safety and create a non-punitive environment that encourages medication-error reporting and a focus on system-based causes of errors. The organization is expected to uphold a patient-safety philosophy, as reflected in the Board of Trustee minutes, the organization’s mission statement, and administrative support. One of the most difficult recommendations to effect under this goal is the shift to a ‘non-punitive” environment; most health care organizations have traditionally invoked a punitive approach to errors committed in the Matthew P. Fricker, Jr. MS, RPh workplace, and corrective actions have focused on disciplining the individual(s) involved in the error. The organization must now focus on the systems that allowed the error to occur, rather than on individuals. Human resource policies must be revised to incorporate this change in philosophy, and the organization must effectively communicate the change, to encourage employees to report incidents and near-misses without fear of disciplinary action. The term ‘non-punitive” should not be misconstrued to mean non-accountable, however. There are situations in which discipline is appropriate—blatant disregard of policy, intentional commission of an error, or unlawful or egregious behavior, for example. Each organization must define such situations and, again, effectively communicate those to employees.
• Develop a medication-safety education program for all new and existing employees.
Under the direction of the P&T committee, medication-safety orientation materials should be developed for the disciplines involved in the medication-use process. Although many of the steps involved in medication safety are common to all disciplines, each discipline has a unique role in ensuring that patients receive their intended medications. Therefore, the organization should consider developing separate informational pieces for physicians, pharmacists, nurses, pharmacy technicians/students, and other professionals (e.g., respiratory therapists, radiology technicians). Much of the content included in such a program is already included in employee orientation, but it might be presented in a somewhat fragmented manner; an effort to consolidate this information into one place to serve as a useful reference might be warranted. Such a document, appropriately updated to reflect current medication-safety issues, can serve as a means for annual education and as a basis for assessing employee competence. Also included under this goal: the organization should work through the appropriate patient-education committee to develop a patient information sheet describing the patient’s role in ensuring his/her safety while in the hospital (and upon discharge). Medication safety is one component of this effort.
• Recognize safety innovations.
Employee involvement in medication safety should be encouraged by the organization. It might be productive to implement an employee-suggestion program for improving medication safety. Front-line employees who routinely work within the system might view processes differently than management, and could see opportunities for improvement that management might miss. Reward programs should be developed for employees who make suggestions that are successfully implemented. Recognition of an employee who has suggested a safety innovation might spur other employees to do the same. It is also important to ensure that employees receive feedback on system changes, to underscore the organization’s commitment to medication safety.
• Disclose medical errors to patients.
To be consistent with new Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards, the organization must develop procedures for informing patients when errors have occurred. The policy should include a statement indicating who, within the organization, is responsible for providing this disclosure, and should also include guidelines on how the facts should be disclosed. An effective employee-assistance program should be available for staff who are involved in medication errors and might require emotional support in the aftermath.