Institute for Healthcare Improvement: BTS Collaborative: Reducing High-Hazard Adverse Drug Events

Overview

The Breakthrough Series is IHI’s collaborative improvement methodology to rapidly deploy major changes that produce breakthrough results in a specific clinical or operational area. Collaboratives last for approximately 10 months under the guidance of an IHI panel of experts, and are open to IMPACT and non-IMPACT member organizations.

Enrollment for this program is closed. If you are interested in receiving information for the next offering of this program, please send an email to info@ihi.org.

Click here to listen to an informational call led by the faculty of this Collaborative.

The Problem

The Solution

Adverse drug events (ADEs) occur in 6% to 10% of hospitalized patients and each year thousands of patients die from drug-related injuries. The costs of adverse drug events are substantial — as much as $4,000 to $5,000 per ADE in teaching hospitals. Barriers to reduction of ADEs include the complexity of the medication system, a punitive approach to errors and unwanted conditions which inhibits reporting, and the tradition of focusing corrective action on individuals rather than on the underlying systems failures.

Narcotics and anticoagulants are two high-risk medication categories that are known to cause a significant portion of medication harm. Adverse events from these types of medications often have serious consequences for patients. Despite many known safe practices that can prevent or reduce harm, they are inconsistently applied, and few, if any, hospitals practice all of them.

ADEs can be significantly reduced by implementation of known safety practices, such as unit dosing, standardization of prescribing rules, computerized drug profiling in the pharmacy, standardized dosing regimens, and redesign of medication processes using Failure Modes and Effects Analysis and proven human factors principles.

In addition, developing a culture of safety through the use of briefings, communication techniques and leadership involvement leads to an environment where staff more readily prevent, detect, and mitigate patient harm. IHI has been working with committed organizations for many years on ADE reduction, many of whom have realized a tenfold decrease or greater.

Areas of Focus

This Breakthrough Series Collaborative will focus on reducing ADEs in narcotics and anticoagulants, specifically:

Measuring harm
Reconciliation of medications
Building a safety culture
Improving core medication processes

Aims

To decrease adverse drug events from the use of anticoagulants and narcotics by 50%:

Reduce the Risk Priority Number of a core medication process by 50% through the use of Failure Modes and Effects Analysis
Reduce errors from medication reconciliation by 50%

Related Learning Opportunity

Creating High-Performance Teams

Jump start your group into becoming a team by attending a one-day workshop on creating effective teams, offered prior to the first Learning Sessions.