Make "pro-change" your New Year's Resolution
From the January 13, 2005
As the New Year began, an editor of the Journal for
Healthcare Quality (published by the National Association
for Health-care Quality - NAHQ) asked ISMP the following question:
The ISMP Medication Safety Alert! is in its 10th
year of publication. What would you consider to be the most
significant impact of this publication?
In response, we expanded on the premise that the newsletter's
impact is really threefold: learning, standards, and change.
There is ample evidence to believe that this newsletter
is widely distributed and used as a vehicle for learning
about medication errors and their prevention. Likewise,
accrediting and regulatory agencies are increasingly using
the ISMP newsletter to evaluate, revise, or create standards
of care aimed at preventing patient harm from medication
errors. However, data from our 2004 ISMP Medication Safety
Self Assessment for Hospitals show that there is room for
improvement when it comes to using published error experiences
from other organizations as a vehicle for proactive change
Both the 2000 and the 2004 self-assessments asked hospitals
whether a convened interdisciplinary team routinely analyzes
and uses published error experiences from other organizations
to proactively target improvements in the medication use
process. While significant improvement occurred between
2000 and 2004, the most recent data still show that only
50% (29% in 2000) of more than 1,600 hospitals perform this
important function consistently throughout the organization.
A new 2004 self-assessment item offers additional proof
that we need to be more proactive in 2005. Just 35% of hospitals
consistently convened an interdisciplinary team to evaluate
new technologies and evidence-based practices that have
been effective in reducing errors in other organizations
to determine if it can improve its own medication management
system. And remember, this is just a necessary precursor
to pro-change, not change itself.
Further anecdotal evidence that health systems may not
be effectively using published error experiences from other
organizations as a vehicle for pro-change can be found in
this newsletter itself. For 3 years, we have published a
regular feature, Worth Repeating. Sadly, there is never
a lack of material for this column. The same types of errors
continue to happen, even after widespread publication.
What can we learn from hospitals that have been successful
with pro-change? While this is an area worthy of further
exploration in 2005, here are a few suggestions we have
uncovered thus far:
Assign a specific professional(s) to routinely search
the literature for new technologies, evidence-based practices,
and published error experiences from other organizations.
This important function should be part of the staff member's
job description and performance evaluation.
Make pro-change a standing agenda item for discussion
by the current interdisciplinary team that reviews internal
medication safety issues. Ensure that the team routinely
reviews and analyzes information about external errors and
other patient safety topics, and determines the need for
pro-change within the organization. Set a routine time for
the team to meet, at least monthly.
Be prepared for each meeting. Some hospitals have
found it helpful to create a worksheet that succinctly describes
published errors, prevention recommendations, and related
safeguards already in place in the hospital. Click here for an example of a worksheet used by a hospital to assess
its need for pro-change based on the ISMP Medication Safety Alert! (Other examples will be posted on our
website as submitted to ISMP. See below for more details.)
Establish a systematic way to review the new information,
assess the organization's current status related to each
item, and prioritize the items based on its potential to
cause or prevent patient harm.
Determine a workable action plan, which includes
process/outcome measures that can be used to evaluate success,
and timelines for completion. Some hospitals have found
Gantt charts useful to graphically represent the timing,
duration, and people responsible for specific tasks required
to complete a project.
Assign staff/manager/leader teams most suitable
for the specific actions to ensure that pro-change occurs.
Implement a small test of the change first. Make
any necessary revisions uncovered during the test, and then
spread the pro-change throughout the organization.
If you have additional suggestions or tools for planning
and implementing pro-change that have been successful in
your organization, please share them with us (firstname.lastname@example.org
or fax to 215-914-1492) so we can post them on our website.
Let's make 2005 the year for pro-change. While we still
will have to look backwards at times to uncover the root
causes of errors that have occurred within an organization,
let's not forget to look forward, learning from published
errors, anticipating the same risks, and planning pro-changes
to make substantial improvements in patient safety.