Survey shows how hospitals use the
ISMP Medication Safety Alert! to improve medication safety
From the February 9, 2000 issue
How are people translating the ISMP Medication Safety Alert!
recommendations into action? What barriers do organizations
face in disseminating the newsletter and implementing recommended
strategies? In September 1999, we distributed a subscriber
survey to gather such information. The findings from the survey
provide some valuable insight for those who are striving to
use our publication to guide safe medication practices. Subscribers
who responded told us that the most significant barriers to
widespread distribution of the newsletter were lack of an
established system for internal distribution and lack of assigning
responsibility to an individual to accomplish this function.
Other significant barriers included time and personnel constraints
and lack of an internal e-mail system to facilitate distribution.
In contrast, respondents who reported widespread distribution
of the newsletter had established efficient systems for distribution
and had dedicated staff to accomplish this function. The most
significant barriers to implementing many of the recommended
system-based error reduction strategies included limitations
in time, manpower, and financial resources, respectively.
However, lack of physician support, administrative support,
nursing support, and resistance to change also rated high
as barriers. On the other hand, it was clear that respondents
who have implemented many of the error reduction strategies
suggested in the newsletter have been successful due, in large
part, to practitioners and multidisciplinary teams that are
dedicated to this purpose and provided with the necessary
time and resources to redesign systems. In a follow-up survey,
we asked organizations that had successfully implemented many
of the recommendations in the newsletter to describe at least
five of the most significant changes. Most respondents included
more than five examples, which clearly demonstrated their
organizations' commitment to providing leadership and the
necessary resources to make improvements. Interestingly, few
changes, such as robotics and bar coding, required significant
human and financial resources. Yet, the time and financial
commitments required for most of the successful error reduction
strategies undertaken by these organizations would likely
be quite manageable for most organizations.
It was heartwarming to learn from readers that so many positive
changes have been stimulated by our newsletter. The most frequently
implemented ISMP-recommended error reduction strategies were
related to standardization, safe drug storage, computer enhancements,
regular review of external errors, and targeted practitioner
education. For example, protocols have been established for
electrolyte replacement, Cerebyx, TPA, heparin, methadone,
and conscious sedation. Products with look-alike names or
packaging have been purchased from different manufacturers
or stored separately. Computer and MAR alerts have been designed
for neuromuscular blocking agents, concentrated oral morphine
products, lipid-based products, and drugs with look-alike
names, and label warnings have been applied. A list of prohibited
abbreviations has been established and compliance has been
monitored. Maximum doses for chemotherapy have been established
and entered into pharmacy computer systems. Order entry processes
have been redesigned for complex TPN orders and chemotherapy
protocols. Alert messages have been assessed and redesigned
to allow only clinically significant alerts to appear. Food
allergies have been added to the computer system to alert
staff to peanut allergies when Atrovent is prescribed. Concentrated
electrolytes, ketamine, concentrated esmolol, and Cerebyx
have been removed from patient care units. Nifedipine capsules
have been removed from crash carts and sublingual administration
prohibited. Drug samples have been controlled better with
pharmacy oversight. Pumps without free-flow protection have
been removed from facilities, and others have been reprogrammed
to limit the selection of dosing parameters and automatically
select the correct protocol once a drug is entered. Morphine
PCA has been limited to a single concentration. In pediatric
units, drip concentrations have been standardized, the use
of the "Rule of 6" has been abandoned, and full unit dose
dispensing of all NICU medications has been instituted. Eye
drop containers are no longer used for multiple patients.
Double check systems for chemotherapy calculations and preparation
and PCA and heparin pump set-ups. Check systems between nursing
and pharmacy during medication cart exchanges have been established
on pediatric units. Systems that support widespread practitioner
education (newsletters, alert systems, storyboards) have been
designed and information from the ISMP Medication Safety Alert!
has been incorporated routinely into the orientation process.
The practice of tabulating error rates based on practitioner
reporting has been abandoned and many respondents have embraced
a system-based, non-punitive approach to error reduction.
Finally, the examples cited by respondents clearly demonstrate
that a process had been established for regular, multidisciplinary
review of the ISMP Medication Safety Alert! and "Action Agenda"
to identify and implement proactive error reduction strategies.
In the end, the results of this survey suggest that error
reduction strategies are most successful when responsibility
for medication safety is clearly embraced by individuals and
multidisciplinary teams that are given the ample time and
resources to discharge this duty.