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ISMP Medication Safety Alert


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Medication safety exam or program for new staff
Allina Hospitals and Clinics in Minneapolis, MN


Primary Author      Barb. Schmeichel, R.N.
Content Contributors
     Ruth Ann Johnson MS
     Bruce Scott MS FASHP
     Jamie Sinclair RPh
     Skip Valusek
     Todd Whalstrom, MS
     Carl Woetzel, MS PharmD

Learning Objectives
Upon completion of this topic the participant will:

  1. Recognize the importance of patient safety and Allina's safety initiatives (view the Allina Patient Safety Presentation).
  2. Recall the Allina Safety Principles and apply them to a professional experience (small group activity with visuals).
  3. Identify the goal, means and importance of reporting medication accidents (complete a Patient/Visitor Safety Report activity).
  4. Identify the systems involved in medication administration (view video and overhead).
  5. Recall high-risk medications (view overhead).
  6. Recall the medication administration policy and means of accessing this information (review hospital-specific policy).
  7. Practice safe medication administration practices consistent with the Allina Safety Principles and the hospital's protocols (observation in practice with a validation checklist for unit preceptors).

Learning Plan (Facilitator-led class)
The participant will:

  1. 2" Recall a medication accident they were involved in and identify an intervention that would prevent this from happening.
  2. 10" View transparencies or Power Point Presentation - "Allina Patient Safety" (Objective 1)
  3. 10" View video and "systems" slide - Beyond Blame (objective 3, 4)
  4. 10" Participate in small group activity - Patient Safety Principles (objective 2)
  5. 10" Practice safety report completion - Patient/Visitor Safety Report, scenario, directions (objective 4, 5)
  6. 20" Participate in small group to review and summarize key points of hospital specific medication administration policy (objective 6)
  7. 2" Recall 6 high-risk medications and 4 Principles of Patient Safety

Materials Needed
Life Saver candies
Allina Patient Safety transparencies or Power Point Presentation
Large Allina Patient Safety Poster and "Principles" signs
"Beyond Blame" video
"Systems" slide
Small cards for each participant
Patient/Visitor Safety Report scenario, form and directions
Hospital-specific medication administration policy
Easel paper and large colored markers

Principles of Patient Safety Details of Facilitator-led class


  • Seat participants in small groups. Display the Allina Patient Safety poster in the front of the room.
  • Distribute lifesaver candies to all participants to introduce the topic of Safety but instruct them NOT to eat them yet.

"This year the Institute of Medicine reported that 44,000 - 99,000 deaths occur in hospitals every year from errors or accidents. A portion of these accidents is due to medication errors. In response, Allina has made Patient Safety a corporate initiative. They have a goal to reduce and ultimately eliminate medication errors in Allina Hospitals. To accomplish this a comprehensive plan for improvement is being initiated. Efforts are directed toward

  • changing our culture to one that is blame resistant and values safety first
  • education/awareness of the importance and complexity of patient safety
  • changing systems to prevent accidents and learn from those that occur."
"I'd like you to remember a medication error that you were either directly involved in or that you know about. Remember as many details as you can. (Pause) Remember the people, issues and feelings involved. (Pause). Now use the small card provided to write one or two simple interventions that would prevent this error from happening again. Save this suggestion for later. After you have written a prevention intervention, reward yourself as a "Lifesaver" with a lifesaver candy.

Allina Patient Safety slides - 10"
Show the Power Point slides or use transparencies to present the Allina perspective. "This information will help you understand more about safety, and what Allina is doing."

"Beyond Blame" video
Introduce the video: "As mentioned, Allina intends to support a culture that encourages all staff to question and improve systems and information and to report accidents or errors for learning and prevention.
While you watch this video consider:

  • the multiple systems involved with medication administration
  • the impact of an organizational culture that values learning instead of blaming
Facilitator - after the video, ask participants to recall of the systems that are involved in the whole process of medication administration. Then show the slide that illustrates the 6 systems and the potential for error in each one.
Explain that we must always be aware of the responsibility of "personal vigilance", but that we need to be aware of other systems that may affect safety also.

Principles of Patient Safety - 10"
"Allina has 9 "Principles of Medication Safety" that support a multiple-system, blame-free culture. These principles should be your guideline for safe patient care."

  • Distribute the 9 individual "Patient Safety Principles" signs to the group (with large classes, have them "partner") to each participant or small groups of participants.
  • Have small groups look at their principle, decide what it means for patient safety, and give a specific example of how that safety principle could prevent a medication administration error.
  • Give the participants 3+ min. to think or discuss this and then have each group present their principle, and example. Some ideas for examples:
      First Do No Harm: When a medication is overdue, your are really busy, and you notice that the dosage is different than you have used before, instead of administering the medication in a hurry and moving on, First Do No Harm! Ask the pharmacist, call the physician, and clarify with a resource.
      Nothing is Taken for Granted: Do not assume that the medication in the Pyxis machine listed for that drawer is actually the medication it's supposed to be. Pharmacists are human too, and the incorrect medications may inadvertently be placed in the Pyxis machine.
      Communication: Call the Dr to explain the patient's response to the medication before administering it again if it is unusual.
      Teamwork: Ask the HUC to call the pharmacy for a consult, or the Dr. to clarify an order.
      Report: We learn and improve systems by reporting errors. It benefits the patient, hospital and staff.
      Safety is a System: Realize that another system may be flawed and stop the process. If two drugs are packaged alike and placed in the same area, change the way they are stored together, work to get a different packaging, etc.
      Engage the Patient: Sometimes it is the patient that is the "fail-safe." They may comment that they have "never taken a drug that looks like that," or that they are allergic to PCN and their Dr. told them not to take this similar drug, etc.
      Learning is the Goal: We are supporting a "blame-resistant culture" so we can report accidents, change and improve systems and promote safety.
  • As groups present their principle they place their sign around the "lifesaver" on the Allina Patient Safety Poster and then eat their lifesaver candy.
  • Complete the reports on all the Principles. Leave the poster with the principles signs in a visible place.
  • Finally, ask the participants to look at the medication error prevention strategy they wrote down at the beginning of the class and note which one of the safety principles is represented by their intervention.

Safety Report practice
Facilitator: "Allina employees report all medication errors/accidents, because that is one way we learn how to prevent accidents."

Introduce the Patient/Safety Visitor Report Learning Packet with the form, the scenario and directions. Ask them to read the material and then complete the form for the patient in the case study.

Hospital Policy
Introduce the your hospital's medication administration policies by giving a brief situation: Facilitator: "It is the first day of your clinical orientation and you are responsible for giving your assigned patients' medications. You have to administer a medication that follows a specific protocol (give an example from your hospital) and you can't remember ( mention some important part of the protocol). Your preceptor is busy with an emergency situation, no one else seems available, and you know that you will "make no assumptions" and will "first do no harm" (two of the Allina Safety Principles) so you will need to review the policy. Where can you get this information?"

Explain the system to access policies, procedure, and protocols in your hospital (Allina Knowledge Network, hard copy manuals, etc.) and how/where they will learn to use the on-line system.

Distribute the general medication administration policy for your facility and ask them to:

  • Read the entire policy
  • Consult with their small group to summarize the 7 key points of the policy
  • Write the key points on their easel paper using the colored markers (give them 15")
  • Present the key points to the group
Present a summary of any important points that the groups did not identify, such as Chemotherapy, Heparin, Insulin, PCA/IV Pump, etc. protocols.

Class Review (very quickly)

  • Have them stand up and find a learning partner. One partner must recall the 6 high-risk medications, and the other partner must recall 4 of the nine Principles of Medication Safety (they can help each other).
  • Ask the large group to repeat the name of the system to access policies and procedures.
  • Thank them for their participation.


Self-Study Curriculum

Learning Objectives
Upon completion of this topic the participant will:

  • Recognize the importance of patient safety and Allina's safety initiatives (Allina Patient Safety Presentation).
  • Recall the Allina Safety Principles and apply them to a professional experience (small group activity with visuals).
  • Identify the goal, means and importance of reporting medication accidents (Patient/Visitor Safety Report activity).
  • Identify the systems involved in medication administration (video and overhead).
  • Recall high-risk medications (overhead).
  • Recall medication administration policy and means of accessing this information in the patient care area (hospital-specific policy review).
  • Practice safe medication administration practices consistent with the Allina Safety Principles and the hospital's protocols.

Learning Plan The participant will:

  1. Write a medication accident example and a safety intervention that could prevent this accident from happening.
  2. Read the "Allina Patient Safety" presentation
  3. View the Beyond Blame video and the "systems" illustration
  4. Read and apply the Allina Patient Safety Principles to appropriate clinical situations and select an Allina principle and a medication system that that was illustrated in their exemplar (see #1 above)
  5. Practice completion of the Patient/Visitor Safety Report using a patient situation
  6. Read and summarize the hospital -specific medication policy
  7. Identify a possible situation that would require reviewing this policy and recall the means to access this resource on a patient care unit and
  8. Recall 6 high-risk medications and 4 Principles of Patient Safety
  9. Complete the Patient Safety Review Crossword Puzzle (optional)
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