Pilot Team:

• Sharon K. Meyer, Executive Director, Pharmacy, Iowa Health-Des Moines
• Kathie Nessa, RN, Director of Quality Improvement, Iowa Health-Des Moines  
• Marilyn Harden, RN, Head Nurse, Iowa Lutheran Hospital

System-wide Spread Teams:

Iowa Health System (IHS) Patient Safety Implementation Team which included representatives from across all IHS hospitals: physicians, nurses, pharmacists, quality improvement staff, risk managers, educators, and patient and family representatives

• Spread Aim: To spread the use of Unit Briefings across Iowa Health System's ten hospitals to discover unsafe conditions and opportunities for reducing harm associated with medications. Unit Briefings were one element of the change package for improving medication safety.
• Medication Safety Improvement Aim: To reduce adverse drug events tenfold across Iowa Health System in 12 months.

Measures to Track Spread of Specific Changes:

• Percent of hospitals using Unit Briefings (Goal: Spread use of Unit Briefings to 100 percent of hospitals and units targeted)
• Perspectives of staff participating in the Unit Briefings:
  • Usefulness of Unit Briefings in helping to reduce the risk of medication errors
  • The value of Unit Briefings, on a scale of 1 to 10, in improving the quality of care
  • How much the Unit Briefings made individuals more aware of medication safety issues
  • Whether staff recommend that the sessions continue
• Number of ideas/concerns collected and percent completed or acted upon

Outcome Measures:

• Percent of admissions with an adverse drug event across all IHS hospitals [Result: Adverse drug events were decreased by 75 percent in eleven months across IHS hospitals. We collected data for this measure using the Trigger Tool for Measuring ADEs to review charts monthly at each hospital.]
• Percent of staff reporting a positive safety culture [Measured this system-wide using an annual survey (17 Likert items) of employee perspectives of the culture of safety.]

Iowa Health System (Iowa and Illinois) tested the use of Unit Briefings (also known as Safety Briefings) in one hospital to improve medication safety, and then spread the change to other system hospitals within one year.

The Unit Briefings were tested at Iowa Health-Des Moines' three hospitals and spread across these hospitals: Allen Health Systems, Waterloo; The Finley Hospital, Dubuque; St. Luke’s Hospital, Cedar Rapids; St. Luke’s, Sioux City; Trinity Health Systems, Fort Dodge; and the three hospitals of Trinity Regional Health System in Davenport, Iowa and Moline, Illinois.

Unit Briefings were tested in one unit and spread successfully from one unit to 40 units in the pilot hospitals. Subsequently, IHS spread Unit Briefings state-wide to system hospitals. 

Specific changes at the unit level developed through Unit Briefings included:

• Engaged the pharmacists with nursing units to collaborate on discovering unsafe conditions and ways to improve the processes
• Improved the knowledge of nurses and pharmacists of best practice activities in medication safety and how these practices apply to the specific units' needs
• Changed medications in Pyxis to reduce potential of unclear dosing needs (e.g., replaced two drugs with a slightly higher cost combination drug and moved splitting of doses from nursing units to the pharmacy)
• Designed a data collection and feedback mechanism to gather findings and let the units know what happened to their ideas
• Engaged managers in the feedback process
• Added implementation of changes discovered through Unit Briefings to the managers' annual review expectations
• Created support document for frequently asked questions and attached it to the Pyxis units
• Replaced slow Pyxis screen
• Gave Radiology nurses access to Pyxis
• Added Respiratory Therapy drugs to Pyxis
• Increased par levels of stock-antibiotics for Pediatrics and Neonatal Intensive Care Unit
• Decreased some medications to allow more space for others
• Obtained a larger locked medication box to accommodate Cardizem needs on telemetry
• Provided clearer labeling of compounded medications

Successful Pilot Unit Results:

• Radiology, nursing, transportation staff surveys:
  • 100 percent of respondents indicated Unit Briefings were useful in reducing errors
  • 100 percent of respondents noted Unit Briefings made them more aware
• Unit Briefings were found to be of value in improving care for 100 percent of nursing and transport staff and 75 percent of Radiology staff
• Staff recommended to continue Unit Briefings after 5 days of testing:
  • Nursing staff on the pilot unit focused on medication safety (77 percent) 
  • Radiology staff on pilot unit focused on devices and equipment (89 percent) 
  • Transportation staff focused on devices and equipment (89 percent)

Lessons Learned:

We spread the concept and tools of Unit Briefings to all Iowa Health System hospitals and learned the following: 

• Used a steering team to manage logistics of collaboration between QI, nursing, and pharmacy
• Addressed social aspects of change
• Developed a communication process across the hospitals and across the system
• Facilitated spread across hospital units through prepared toolkits and planning discussions held in nursing leadership meetings
• Communicated, communicated, communicated using multiple channels
• Started small but believed in the value of Unit Briefings
• Improved tools through early testing to increase clarity and save time
• Provided feedback to those who offered ideas and concerns (this is crucial and needs to happen quickly)
• Developed and implemented strategies to "hardwire" changes
• Established and documented standard processes
• Used measurement and audits
• Established multidisciplinary teams
• Established standard agenda items for key meetings
• Established annual culture survey for employees
• Tracked and followed through on employee ideas for continued involvement
• Assigned ownership of data collection and feedback
• Defined staging plan for spread across the system
• Hospitals defined spread to individual hospital units
• Learned that Unit Briefings can be used for other unsafe conditions (e.g., reducing falls, reducing infections, follow up on JCAHO patient safety goals, and discovering examples of device design issues)

Barriers:

• As the number of units engaged in the spread initiative grew larger, the magnitude of tracking and managing the information and feedback became a struggle. An Access database was developed, resources were borrowed to do data entry, and processes for collecting the ideas were streamlined.
• A barrier for one smaller hospital was finding resources to manage Unit Briefings and Patient Safety Leadership WalkRounds. The solution that evolved is a hybrid model that combines both concepts.

Gail Nielsen, Patient Safety Administrator
Iowa Health System
nielsega@ihs.org