The Joint Commission Journal on Quality and Patient Safety
Preventing Harm from High-Alert Medications
Section snippets
Three Strategies to Improve Medication Safety
Some harm may be prevented by improving medication management, changing prescribing patterns, adding other therapies to minimize untoward side effects, and identifying harm soon enough to be able to mitigate it before it becomes serious. Human factors experts and reliability science suggest three strategies to improve medication safety.13 The first is to design systems that prevent errors and harm. The design should take into account the complexity that exists in health care, the team
Executing System-Level Changes
Three essential elements are needed to execute system-level changes in an organization: will, ideas, and execution.15 Will is developed by examining the status quo in an organization and agreeing that it is no longer acceptable. The goal is to reduce the rate of medication-related harm experienced by patients through the implementation of a number of safety practices. Participation in the 5 Million Lives Campaign is one indicator that the organization has the will to change the status quo.
Getting Started
The list of high-alert medications selected for the 5 Million Lives Campaign is not all inclusive. Hospitals may choose to add other medications on the basis of their own risk identification.
The first step should be to determine if standardized processes are in place. Conduct an audit of randomly selected patients who should be treated using standardized protocols or order sets to learn how reliably they are being used. Begin by auditing a small sample of charts, as few as 10 on a unit; if the
Measurement
Measurement tells you if the changes you are making are improving the safety of high-alert medications. If you’re just starting, ask some basic yes-or-no questions before starting measurement in earnest. These questions provide valuable information very quickly, before investing the time to set up a more rigorous, long-term measurement structure. For high-alert medication work, ask the following yes-or-no questions:
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Have you developed a protocol or order set for all appropriate medications?
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Is
Conclusion
The 5 Million Lives Campaign’s focus on high-alert medications is part of an overall strategy to reduce medically induced harm. The campaign’s goal is to achieve a 50% reduction in harm related to high-alert medications. Employing strategies such as standardization and simplification will provide the foundation for improved medication safety.
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This article is the second in the series on the 5 Million Lives Campaign, the Institute for Healthcare Improvement’s national initiative that aims to protect patients from five million incidents of medical harm in United States hospitals between December 2006 and December 2008.