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Medication Safety Subcommittee works
to reduce errors and
enhance safety
By Stacey L. Berg, M.D.
Medical error has been a topic
of intense discussion since the Institute of Medicine’s 1999
report To Err is Human: Building a Safer Health System
called widespread attention to estimates that between 44,000 and
98,000 people die each year in the United States as a result of
potentially preventable medical errors. At Texas Children’s
Hospital, prevention of such errors is an important part of
overall patient safety efforts. The Pharmacy and Therapeutics
Committee established a Medication Safety Subcommittee in 2000
in order to enhance focus on prevention of medication errors.
The
goals of the Medication Safety Subcommittee are to:
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Provide leadership
and determine the research and tools needed to enhance knowledge
about safe medication practices;
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Develop and implement
policies and procedures to support safe medication practices;
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Determine
opportunities to encourage reporting; and
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Establish standards
and expectations as they relate to incident reporting, review
and follow-up.
The committee’s first
priorities were to review the most common errors and mistakes at
Texas Children’s Hospital, establish priorities for creating a
safer medication environment, identify data or measurement tools
needed to quantitate improvements and, most importantly,
identify opportunities for improvement. The subcommittee meets
six times a year and works closely with the hospital’s Patient
Safety Executive Committee.
Much of the work of the
Medication Safety Subcommittee goes on behind the scenes. For
example, at each meeting all serious medication incidents are
reviewed, and the subcommittee determines whether further action
is warranted to analyze the incident or prevent similar events.
Certain severe adverse events related to medications are
reviewed by individual subcommittee members with particular
expertise in the area, who then report back to the full
subcommittee. In addition, the subcommittee reviews the numbers
and types of pharmacist interactions with prescribing
practitioners throughout the hospital. This overview permits the
subcommittee to identify patterns that might otherwise escape
easy detection.
New
initiatives implemented
Some safety enhancements result
from direct interactions among the subcommittee, Pharmacy and
practitioners. For example, Critical Care units have worked
closely with Pharmacy to develop standardized concentrations for
drips in order to decrease the likelihood of calculation errors.
Another exciting new initiative is the Interventions by Floor
feedback process begun in October 2004. In this process, unit
pharmacists take a few minutes each week to share with the house
staff reports that break down pharmacist interventions by floor,
so that every intervention becomes a learning tool for a broad
group of practitioners. Through initiatives like these, the
Medication Safety Subcommittee is working to help make Texas
Children’s a safer place for all our patients.
Stacey L. Berg, M.D., is
co-director of Texas Children’s Cancer Center Clinical
Pharmacology Group and associate professor of Pediatrics at
Baylor College of Medicine.
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