Survey shows how hospitals use the ISMP Medication Safety Alert! to improve medication safety

How are people translating the ISMP Medication Safety Alert! recommendations into action? What barriers do organizations face in disseminating the newsletter and implementing recommended strategies? In September 1999, we distributed a subscriber survey to gather such information. The findings from the survey provide some valuable insight for those who are striving to use our publication to guide safe medication practices. Subscribers who responded told us that the most significant barriers to widespread distribution of the newsletter were lack of an established system for internal distribution and lack of assigning responsibility to an individual to accomplish this function. Other significant barriers included time and personnel constraints and lack of an internal e-mail system to facilitate distribution. In contrast, respondents who reported widespread distribution of the newsletter had established efficient systems for distribution and had dedicated staff to accomplish this function. The most significant barriers to implementing many of the recommended system-based error reduction strategies included limitations in time, manpower, and financial resources, respectively. However, lack of physician support, administrative support, nursing support, and resistance to change also rated high as barriers. On the other hand, it was clear that respondents who have implemented many of the error reduction strategies suggested in the newsletter have been successful due, in large part, to practitioners and multidisciplinary teams that are dedicated to this purpose and provided with the necessary time and resources to redesign systems. In a follow-up survey, we asked organizations that had successfully implemented many of the recommendations in the newsletter to describe at least five of the most significant changes. Most respondents included more than five examples, which clearly demonstrated their organizations' commitment to providing leadership and the necessary resources to make improvements. Interestingly, few changes, such as robotics and bar coding, required significant human and financial resources. Yet, the time and financial commitments required for most of the successful error reduction strategies undertaken by these organizations would likely be quite manageable for most organizations.

It was heartwarming to learn from readers that so many positive changes have been stimulated by our newsletter. The most frequently implemented ISMP-recommended error reduction strategies were related to standardization, safe drug storage, computer enhancements, regular review of external errors, and targeted practitioner education. For example, protocols have been established for electrolyte replacement, Cerebyx, TPA, heparin, methadone, and conscious sedation. Products with look-alike names or packaging have been purchased from different manufacturers or stored separately. Computer and MAR alerts have been designed for neuromuscular blocking agents, concentrated oral morphine products, lipid-based products, and drugs with look-alike names, and label warnings have been applied. A list of prohibited abbreviations has been established and compliance has been monitored. Maximum doses for chemotherapy have been established and entered into pharmacy computer systems. Order entry processes have been redesigned for complex TPN orders and chemotherapy protocols. Alert messages have been assessed and redesigned to allow only clinically significant alerts to appear. Food allergies have been added to the computer system to alert staff to peanut allergies when Atrovent is prescribed. Concentrated electrolytes, ketamine, concentrated esmolol, and Cerebyx have been removed from patient care units. Nifedipine capsules have been removed from crash carts and sublingual administration prohibited. Drug samples have been controlled better with pharmacy oversight. Pumps without free-flow protection have been removed from facilities, and others have been reprogrammed to limit the selection of dosing parameters and automatically select the correct protocol once a drug is entered. Morphine PCA has been limited to a single concentration. In pediatric units, drip concentrations have been standardized, the use of the "Rule of 6" has been abandoned, and full unit dose dispensing of all NICU medications has been instituted. Eye drop containers are no longer used for multiple patients. Double check systems for chemotherapy calculations and preparation and PCA and heparin pump set-ups. Check systems between nursing and pharmacy during medication cart exchanges have been established on pediatric units. Systems that support widespread practitioner education (newsletters, alert systems, storyboards) have been designed and information from the ISMP Medication Safety Alert! has been incorporated routinely into the orientation process. The practice of tabulating error rates based on practitioner reporting has been abandoned and many respondents have embraced a system-based, non-punitive approach to error reduction. Finally, the examples cited by respondents clearly demonstrate that a process had been established for regular, multidisciplinary review of the ISMP Medication Safety Alert! and "Action Agenda" to identify and implement proactive error reduction strategies. In the end, the results of this survey suggest that error reduction strategies are most successful when responsibility for medication safety is clearly embraced by individuals and multidisciplinary teams that are given the ample time and resources to discharge this duty.