The Acute Medical Unit (AMU) at Vancouver General Hospital is a 43-bed unit admitting adult patients who require medical management of diverse diagnoses. Although many of the patients are critically ill, there are no ventilators, and no drug therapy requiring electronic cardiac monitoring is administered in this setting. The ratio of nursing staff to patients ranges from 1:2 to 1:6, depending on patient acuity and time of day (e.g., day versus night shift). Three clinical pharmacists are assigned to adult medicine and family practice patients, and the AMU is one site where pharmacists execute their daily pharmaceutical care responsibilities. Automated dispensing cabinets supply narcotics and controlled drugs as well as ward stock. The pharmacy department offers a centralized IV admixture service and traditional 7-day distribution for personal medications.
Patients are admitted to the AMU through the internal medicine and subspecialty services. The Vancouver General Hospital is the major patient care, teaching, and research hospital in British Columbia, and the AMU is consequently a site for core adult medicine rotations in medical school, nursing, and allied health training programs.
The first proposal to initiate medication safety huddles on our unit stemmed from a project conducted 3 years ago by a graduate nursing student, who reviewed the implementation of safety briefings in the adult medical unit of a neighbouring hospital. The student concluded that the number of medication incident reports (anecdotal and written) was unacceptably high and that nurses’ attitudes toward medication errors were generally poor. Although unit management and the nursing environment at the authors’ institution evolved favourably over the ensuing years, our concern about medication safety was underscored by results from studies demonstrating that identified drug-related adverse events occurred predominantly on medical and not surgical services. We decided to conduct a formal 3-month trial of medication safety huddles on our AMU.
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Nursing and allied health care staff were introduced to the concept of a medication safety huddle through a mock briefing presented at a staff meeting. Posters explaining the philosophy of medication safety huddles were posted throughout the unit and in the staff room. Nursing staff was also asked to complete “safety culture” surveys for future comparisons. The same week, medication safety huddles were launched on the unit. Nurses and a pharmacist gathered twice a week at a preassigned area at a designated time. Nursing staff were permitted to continue their patient care duties if necessary and rejoin the discussion when able to do so. Each session was 10 to 15 min long and began with 2 questions posed by the clinical nurse educator to generate dialogue:
• Have you had concerns about medication deliverythis week?
Have you had any errors, near misses, or “good catches” that you would like to share?
During the ensuing discussion, staff members explored potential sources of medication errors or near errors and strategies to prevent these problems in future. The nurse educator collected data from each session, and accountability for follow-through was assigned. A summary was published in the monthly AMU newsletter, detailing discussion and follow-up for specific issues identified in each medication safety huddle.
Ways of resolving safety issues have been classified in 5 categories by our organization’s risk management team:
• Organizational policy: a statement or commitment by the organization of expected outcomes or behaviour (e.g., medication refill orders will be sent 24 h before they are required).
• Internal systems and structures: identification of the processes, structures, and individuals involved in putting a policy into practice (e.g., nurse completes refill order and faxes the order to the pharmacy; pharmacy technician fills the order and sends the refill).
• Front-line tools and forms: communication and documentation records used within systems (e.g., consent forms, patient education brochures).
• Front-line practice guidelines: documents setting out directions on how to implement a procedure and use tools and forms (e.g., patient care guidelines, parenteral drug therapy manual).
• Education: activities to increase awareness and understanding of policies, systems, tools, and guidelines, as well as prescribing appropriateness.