Preventing Harm from High-Alert Medications

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Article-at-a-Glance

Background

One of the 12 interventions that the Institute for Healthcare Improvement (IHI) recommends for its 5 Million Lives Campaign is “Prevent Harm from High-Alert Medications … starting with a focus on anticoagulants, sedatives, narcotics, and insulin.”

Executing System-Level Changes

Three essential elements are needed to execute system-level changes in an organization: will, ideas, and execution. Will is developed by examining the status quo in an organization and agreeing that it is no longer acceptable. Ideas—changes that will make the system safer—can be found in the literature and in the experience of other hospitals and are the basis for the recommended general interventions to reduce errors and harm associated with high-alert medications. Execution, the process of making those changes real, requires commitment from senior leaders and clinical leaders, along with the organizational capacity to improve. The steps in the medication system are so interrelated that a change in one area will affect others’ ability to complete their work. In addition, senior leadership and clinical leadership must visibly support the effort, connecting the reduction in high-alert medication–related harm to the overall hospital goal of harm reduction is essential.

Conclusion

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.

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:

  • Have you developed a protocol or order set for all appropriate medications?

  • 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.

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