Teaming Up to Improve Patient Safety: DISCUSSION

During the pilot project, it became clear that not only were the medication safety huddles helping us to identify important safety issues not captured in medication incident documentation processes, but they were also readily facilitating resolution of these problems.

Over 90% of hospital pharmacies have medication incident reporting systems. One survey has shown that most nurses know that incident reporting is the primary means for identifying medication errors. Unfortunately, however, incident reporting is a reactive approach to medication error. Medication safety huddles emphasize a proactive approach to identifying and preventing error and to effecting change in medication safety systems. In this context, near misses or “good catches” are considered as important as actual errors. Input from nurses has played a critical role in elucidating factors that contribute to medication errors and near misses that may not have been considered previously.

Enhancing pharmacist-nurse relationships is pivotal for safe medication practices in the hospital setting. Both groups of health care professionals have knowledge and skills that are specific to their profession, yet complementary to one another. They have shared concern for rational drug therapy and are uniquely positioned to collaborate in identifying and preventing potential or actual medication error.

The success of our medication safety huddles relies not only on strong facilitation by the clinical nurse educator, but also on the participation of the clinical pharmacist. Numerous studies have proven that pharmacists can reduce medication-related adverse events when they are involved in prescription decisions during bedside rounds with physicians. However, pharmacists must also exhibit leadership in other multidisciplinary initiatives focused on enhancing patient safety. Medication safety huddles represent another opportunity to promote the role of the hospital pharmacist at a grassroots level. Anecdotal feedback from clinical pharmacists participating in mediation safety huddles on our AMU has been exceptionally favourable. Most have found the huddles professionally satisfying, as they are able to share their medication knowledge and advocate safe medication use during these briefings. Conversely, they have learned more about medication delivery systems and administration from nursing staff. The 15-min time restriction makes it feasible for pharmacists to attend the medication safety huddles, as time away from other direct patient care activities is negligible. The response of nursing staff has been similarly positive. On repeat administration of the safety culture survey to nurses 3 months after implementation of medication safety huddles, there was greater acknowledgement that staff are encouraged to report medication errors and greater acknowledgement that medication errors often occur because of system issues rather than an individual’s mistake; respondents also expressed greater confidence in the pharmacy department.
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Ongoing refinement of the medication safety huddles includes streamlining data collection, clearly defining a safety concern as a reportable medication incident, and distinguishing reportable medication incidents from near-miss medication errors. Although solutions to local issues may be quickly implemented on the AMU, accountability and responsibility must also be assigned for issues that cannot be addressed at the unit level, for which a response must be obtained from the hospital organization.

Category: Main

Tags: AMU, Patient Safety

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