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Looking forward: 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 (or pro-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 ( 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.

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