Institute for Healthcare Improvement: Changes - Page 1

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Changes

Medication Systems

Organizations must test and implement changes to existing processes in order to reduce harm from medications. The organizations that have been most successful in reducing harm have made changes in these four key areas:

Developing a culture of safety
Reducing harm from high-hazard medications
Improving medication core processes
Improving medication reconciliation

It is essential to work in all four areas simultaneously to achieve breakthrough results.

All of these changes are evidence-based: They have been reported in the scientific literature or have been tested and proven successful in practice. In each of the four key areas, you will find detailed descriptions of several specific process changes. The changes for high-hazard medications are grouped by the medication or class that may cause adverse drug events. Medication core process changes are grouped into three fundamental medication processes: ordering, dispensing, and administering.

Click here for more information and general tips on Forming the Team, Setting Aims, Establishing Measures, or Testing Changes.

Develop a Culture of Safety
A culture of safety is an atmosphere of mutual trust in which all staff members can talk freely about safety problems and how to solve them, without fear of blame or punishment.

Improve Core Processes for Ordering Medications
Well-designed ordering processes minimize the risk of failures and errors, both of which can lead to adverse drug events (ADEs).

Improve Core Processes for Dispensing Medications
Well-designed processes for dispensing medications minimize the risk of failures and errors, both of which can lead to adverse drug events (ADEs).

Improve Core Processes for Administering Medications
Well-designed administering processes minimize the risk of failures and errors, both of which can lead to adverse drug events (ADEs).

Reconcile Medications at All Transition Points
Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking — including drug name, dosage, frequency, and route — and comparing that list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points within the hospital.

Reduce Adverse Drug Events Involving Anticoagulants
Careful monitoring and management of anticoagulant medications can help prevent harm from over-coagulation or under-coagulation.

Reduce Adverse Drug Events Involving Insulin
Coordinate care processes and use standardized tools when caring for patients on insulin to reduce the risk of adverse drug events (ADEs).

Reduce Adverse Drug Events Involving Narcotics and Sedatives
Careful monitoring and management of narcotics and sedatives can help prevent harm, especially from overdoses.

Reduce Adverse Drug Events Involving Chemotherapy
Use extra safety measures with chemotherapy medications to prevent adverse drug events (ADEs), which can be extremely serious due to the toxicity of these drugs.

Reduce Adverse Drug Events Involving Intravenous Medications
Using known safe practices with intravenous medications and equipment can help reduce their risk of adverse drug events (ADEs).

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How to Improve Forming the Team Setting Aims Establishing Measures Testing Changes Results How-to Guide: Prevent Harm from High-Alert Medications How-to Guide: Prevent ADEs (Medication Reconciliation)

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