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A multidisciplinary team is essential to medication error reduction efforts

From the March 8, 2000 issue

Hospital leaders often ask ISMP, "Where is the best place to start in our efforts to improve the safety of medications used in our organization?" While there are many specific suggestions we could offer, the culture and foundation upon which error reduction efforts are built are paramount to a successful beginning.

As reported in our February 9, 2000, issue, we recently conducted a survey to determine the degree to which subscribers to the ISMP Medication Safety Alert! have been able to translate into practice the many medication error reduction strategies that have been recommended. The results suggested two fundamental factors that most significantly influenced the organization's ability to improve medication safety. First, each successful organization had established a multidisciplinary team that accepted ownership of the medication use process and enthusiastically embraced the opportunity to improve medication safety. Next, it was clear that organizational leadership had demonstrated their commitment to medication safety by providing these teams with the necessary time and resources to discharge their responsibility. You may recall that, while a few respondents reported improvements in automation (e.g., drug dispensing robotics, bar code systems) which required significant human and financial resources to implement, most reported success with implementing error reduction strategies that would not require significant human or financial resources. Thus, the first priority for successful error reduction efforts lies in establishing a multidisciplinary, medication use improvement team and providing the team with reasonable time and resources to assess medication safety and implement system-level changes that make it difficult or impossible for practitioners to make mistakes that reach the patient.

At a minimum, the team should be comprised of front-line practitioners -physicians, pharmacists, and nurses with intimate knowledge of the medication use processes; a strong facilitator, such as a risk management or quality improvement professional, to handle the day-to-day team issues; a representative from high-level administration for support and quick decision-making; and a physician champion to help promote medication safety initiatives. The goals of the team should include the following:

  • promote a non-punitive approach to reducing medication errors;
  • increase detection and reporting of medication errors and potentially hazardous drug use situations;
  • explore and understand the root causes of medication errors;
  • educate practitioners about the system-based causes of errors and their prevention;
  • respond to potentially hazardous situations before errors occur;
  • recommend and facilitate hospital-wide, system-based changes to prevent medication errors; and
  • learn from errors occurring in other organizations through the ISMP Medication Safety Alert! and other published accounts of medication errors, and take proactive measures to prevent similar errors.

The multidisciplinary nature of the team significantly increases the success of medication error reduction efforts. Effective results depend on looking at the complex medication use process as a whole and understanding how major functions interact through varied perspectives and disciplines.

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