Improving Medication Safety Across a Multihospital System

Abstract

The Massachusetts Coalition for the Prevention of Medical Errors and the Institute for Healthcare Improvement have identified 16 best practices to reduce adverse drug events. CareGroup, a network of six hospitals in eastern Massachusetts, multiplied its routine use of these best practices tenfold in the first 18 months of its medication reliability project. Although CareGroup's long-term plans included technological advances such as clinical order entry, computer systems in the pharmacy, dispensing stations on patient floors, and bedside bar-coding, efforts first focused on manual improvements feasible within a year's time. A 4-year strategy involves helping the medication reliability team leaders at each hospital to create impressive local results, publicize the results to their colleagues, invite their clinical colleagues to learn to use plan-do-study-act (PDSA) cycles, and have colleagues lead PDSA cycles themselves. At monthly or bimonthly task force meetings, team results are presented and team leaders are given specific assignments for their teams. One project reduced the time to blood anticoagulation for heparinized patients. The second dramatically reduced lookalike/soundalike errors. The third improved the safety of patient-controlled analgesia. The fourth reduced coumadin incidents. The fifth improved the education of patients about their medications. The sixth greatly reduced the morning dispensing backlog in the pharmacy. Key success factors, in addition to leadership, are the use of data, forcing functions, appropriate pacing, inexpensive practices, and a consultant. The pace needed to implement the best practices overall made it imperative to make many changes rapidly. Often, the team initiated several changes at one time, rather than sequencing changes in successive PDSA cycles. CareGroup faces key challenges in measurement and in spreading and deepening the involvement of clinicians, particularly physicians. It lacks an overall, objective measure of medication safety. Spread of the changes made has been incomplete although the adoption of the best practices increased tenfold (from 6 to 60) in 21 months. Two of the case study interventions--in coumadin order sequencing and dedicating a pharmacy technician to order entry--have been implemented at only one site to date, even though the adoption of the change ideas across hospitals is encouraged. The eventual impact of the changes planned for the future, through automated systems such as computerized order entry, is much larger. Considerable progress is anticipated in adoption of best practices; improvement in top-priority areas of each hospital; improved automation and technology in ordering, dispensing, and administering medication; and better reporting.