Two Effective Initiatives for C-Suite Leaders to Improve Medication Safety and the Reliability of Outcomes
To facilitate such a process, ISMP publishes the Quarterly Action Agenda in January, April, July, and October to summarize important topics published in the ISMP Medication Safety Alert! during the previous three months. The Quarterly Action Agenda was initiated 19 years ago to encourage organizations to use information about safety problems and errors that have happened in other organizations to prevent similar problems or errors in their practice sites. The Agenda is prepared for leadership to use at an interdisciplinary committee meeting and with frontline staff to stimulate discussion and action to reduce the risk of medication errors. Each item in the Agenda includes a brief description of the medication safety problem, a few recommendations to reduce the risk of errors, and the issue number to locate additional information. The Agenda is available in a PDF and Microsoft Word format, the latter of which allows organizations to document an assessment of their vulnerability to a similar error, actions required, and assignments for each Agenda item. This format facilitates reporting to senior leadership about the progress being made to assure that potentially harmful conditions identified as causing external errors are not present or are being addressed. The Quarterly Action Agenda is a useful tool for leaders to proactively address known medication safety issues that could otherwise lead to a harmful patient outcome in their organization.
Learning about barriers to safety through leadership rounds
Healthcare practitioners are repeatedly challenged by unexpected problems in their day-to-day work—up to one system failure every hour has been found to hinder patient care (Tucker, 2009). They respond to these dysfunctional processes with first-order problem solving, addressing only the immediate symptoms they encounter. As a result, they tend to be very skilled and proficient at improvising with what they have on hand to create a solution to the problem or to work around it to get the job done (ISMP, 2016). Unfortunately, roughly 93% of practitioners faced with a problem often fix it in the moment and forget about it, rather than fixing it and then reporting it (Tucker, Edmondson, & Spear, 2001; Edmondson, 2004; Hewitt & Chreim, 2015). They are not necessarily trying to hide this information—instead, reporting often does not occur because they are simply pressed for time after being forced to quickly patch problems so they can carry out their immediate responsibilities (Edmondson, 2004). We tend to encourage this aspect of critical thinking, problem-solving, resilience, and independence, but it comes at the expense of system learning.
While practitioners should be encouraged to both handle unexpected problems and then report them so steps can be taken to address their underlying causes, leaders visible and accessible on patient care units can also serve as a means for learning about these daily system failures and other risks that might threaten patient safety. Leaders who are regularly present in work areas and responsive to practitioners’ messages can quickly learn invaluable information upon which proactive interventions can be planned and implemented to improve the reliability of patient outcomes.
The Institute for Healthcare Improvement (IHI) (which recently announced plans to merge with the National Patient Safety Foundation) has described such a process, called Patient Safety Leadership WalkRounds (IHI Idealized Design Group & Frankel, 2004). These rounds are designed to open the lines of communication about patient safety among employees and senior leaders so learning can occur, and to demonstrate leadership’s commitment to safety and communicate its value within the organization. IHI offers detailed instructions for senior leaders to conduct at least weekly, confidential rounds with three to five employees in rotating patient care units. A sample script with the types of questions to ask covering harm, risk, errors, system failures, and suggestions for error prevention and leadership interventions is provided, along with methods to measure success with the rounds (www.ismp.org/sc?id=2880). Leadership discussions with staff about problems encountered is often less threatening than discussion of actual errors and may be a great starting point that offers invaluable information upon which proactive interventions can be planned and implemented (The Joint Commission, 2017).
Conclusion
Widespread implementation of the Targeted Medication Safety Best Practices for Hospitals and the creation of an infrastructure for learning using the Quarterly Action Agenda and Patient Safety Leadership WalkRounds are efforts worthy of healthcare leaders who truly value medication and patient safety and want to achieve extraordinary results. These tools represent just a snapshot of how ISMP and other organizations can help healthcare leaders communicate and demonstrate the value of patient safety to the organization and their commitment to improve the reliability of patient safety outcomes.
This column was prepared by the Institute for Safe Medication Practices (ISMP), an independent, charitable nonprofit organization dedicated entirely to medication error prevention and safe medication use. Any reports described in this column were received through the ISMP Medication Errors Reporting Program. Errors, close calls, or hazardous conditions may be reported online at www.ismp.org or by calling 800-FAIL-SAFE (800-324-5723). ISMP is a federally certified patient safety organization (PSO), providing legal protection and confidentiality for patient safety data and error reports it receives. Visit www.ismp.org for more information on ISMP’s medication safety newsletters and other risk reduction tools. This article appeared originally in the March 23, 2017 edition of the ISMP Medication Safety Alert!
References
Edmondson, A. C. (2004). Learning from failure in health care: Frequent opportunities, pervasive barriers. Quality Safety Health Care, 13(Suppl II), ii3–ii9. Retrieved from www.ismp.org/sc?id=1735
Hewitt, T. A., & Chreim, S. (2015, March 6). Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting. BMJ Quality Safety, 24(5), 303–310. Retrieved from www.ismp.org/sc?id=1740
Institute for Healthcare Improvement Idealized Design Group & Frankel, A. (2004) Patient safety leadership WalkRounds. Institute for Healthcare Improvement. Retrieved from www.ismp.org/sc?id=2880
ISMP. (2016). 2016–2017 targeted medication safety best practices for hospitals. Retrieved from www.ismp.org/sc?id=417
ISMP. (2016, May 19). Reporting and second-order problem solving can turn short-term fixes into long-term remedies. ISMP Medication Safety Alert!, 21(10), 1–4.
ISMP. (2017, February 9). Using information from external errors to signal a “clear and present danger.” ISMP Medication Safety Alert!, 22(3), 1–4.
James, J. T. (2013, September). A new, evidence-based estimate of patient harms associated with hospital care. Journal Patient Safety, 9(3), 122–128.
The Joint Commission. (2017). The essential role of leadership in developing a safety culture. Sentinel Event Alert, 57, 1–8.
Marx, D. (2017, February 1). There is no such thing as a high reliability organization. What We Believe, 1(1), 1–2.
Reason, J. (1997). Managing the Risks of Organizational Accidents. Hants, England: Ashgate Publishing Ltd.
Senge, P., Kleiner, A., Roberts, C., Ross, R., & Smith, B. J. (1994). The Fifth Discipline Fieldbook: Strategies and Tools for Building a Learning Organization. New York, NY: Doubleday.
Tucker, A. L. (2009, August). Workarounds and resiliency on the front lines of health care. PSNet. Retrieved from www.ismp.org/sc?id=1736
Tucker, A., Edmondson, A., & Spear, S. (2001, July 30). Why your organization isn’t learning all it should. Harvard Business School Working Knowledge. Retrieved from www.ismp.org/sc?id=1738