|
 Reducing the incidence of adverse drug events (ADEs) in a health care organization is not just the job of pharmacy, nursing, or medical staff — it is everyone's job. And "everyone" does not mean only clinical personnel, but anyone who interacts with patients or has a role in any medication process, such as patient transporters and couriers. It is therefore absolutely essential that medication safety efforts be led by a multidisciplinary core team. An organization typically has several teams working on more than one aim at a time, but they should all report to one oversight safety team.
Click here for more information and general tips on Setting Aims, Establishing Measures, Selecting Changes, or Testing Changes.
|
|
|
Any team working on medication safety must be multidisciplinary, with representation from all departments involved in medication processes — doctors, nurses, pharmacists, and other staff with roles in the process, such as couriers and technicians. Team members should be knowledgeable about the daily medication processes in their organization and the associated safety issues. Be sure to get participation from physicians and support from your leadership; these are keys to success.
|
|
|
Example 1: Reducing Harm from Medications
Aim
Reduce adverse drug events (ADEs) in all medical and surgical units by 75 percent within 11 months.
Core Team
The overall core team must be interdisciplinary and must include, at a minimum:
- Nurse
- Pharmacist
- Physician
- Patient Safety Officer (if the organization has one)
Additional team members
- Quality director
- Risk manager
- Representative from information technology
Sub-teams may be formed to work on each of the four key areas (Culture, High-Hazard Medications, Core Medication Processes, and Reconciliation) since work should be done in parallel, but all should be coordinated and overseen by the core team. |
|
|
|
|
Example 2: Reducing Harm from High-Hazard Medications
Aim
Decrease the incidence of hypoglycemia by 50 percent on the medical patient care unit within 9 months.
Sub-team (working with the core team)
- Physician who regularly prescribes insulin
- Nurse from the patient care unit
- Pharmacist
One person, not necessarily the physician, should serve as the day-to-day leader who can apply expertise to (or acquire expertise in) using Plan-Do-Study-Act cycles and testing changes on a small scale. |
|
|
|
|
Example 3: Developing a Culture of Safety
Aim
Have at least 50 percent of staff in the intensive care unit reporting a positive safety culture within 1 year.
Sub-team (working with the core team)
- Nurse manager of the intensive care unit (ICU)
- Physician who works in the ICU regularly (ideally, the medical director)
- Senior leader (someone from senior management of the organization such as the chief executive officer or vice president of nursing)
|
|
|
|
|
Example 4: Improving Medication Dispensing
Aim
Reduce the Risk Priority Number (RPN) of the medication dispensing system by 50 percent within 1 year.
Sub-team (working with the core team)
- Pharmacy representative involved in dispensing
- Pharmacist
- Technician
- Courier (if appropriate)
- Nurse from the unit where changes will be tested
- Representative from information technology
- Quality representative to help with Failure Modes and Effects Analysis
|
| |
|
| |
 |
 |
|
Getting Physicians Involved in Improvement
Why is it important? Lessons learned. Physicians' perspectives.
|
| |
|
