In this together: Collaborative safety interventions improve systemwide care

Pearls from the ASHP midyear

Team-building, reducing distractions, and eliminating duplicate therapies were just a few of the topics spotlighted at the 2012 American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting & Exposition. Medication safety experts weighed in on how to implement new initiatives and processes to improve patient care and make it safer.

Distraction reduction

Alina D Bulgar, PharmD, PhD, Coordinator of Medication Regulatory and Accreditation Services at the Cleveland Clinic, described the process of developing interventions to reduce distractions during the medication administration process.

Funded by a research grant from the Cardinal Health Foundation, the project was designed not only to identify safety interventions, but also to evaluate the effectiveness of the interventions in reducing interruptions and distractions.

The interventions assessed included a “med pass time out,” which was a protected time of 45 minutes during peak hours when medications are administered. During the time out, “the nurses turn their wireless work phones off and all the calls are triaged by the unit coordinator,” said Bulgar. Other interventions included a quiet zone around the Pyxis machine, do not disturb signs for patient’s rooms, informational sheets for patients and families, and a medication administration checklist.

After implementing the interventions, “we were able to show a 50% reduction in the overall number of interruptions or distractions during medication administration,” said Bulger. All of the types of disruptions, such as phone calls, missing meds, noise, and conversations “were impacted by these interventions,” Bulger added.

Duplicate Dilemma

“The Joint Commission tells us that therapeutic duplication is among the top noncompliance issues,” said Deb Saine, MS, FASHP, FSMSO, Medication Safety Manager at Winchester Medical Center/Valley Health in Winchester, VA. After analyzing data at her institution, Saine and her team discovered an issue with anticoagulant duplication.

To resolve the problem, “we looked at people issues like accountability [and] competencies, technologies, our organization, our training, and looked at our process that we used for managing [medication] orders,” said Saine. Once problems were identified, the group developed countermeasures to help prevent duplicate therapy.

Examples of countermeasures to resolve anticoagulant duplication included an education series about the importance of screening for duplicates in therapy, a “speed bump” in the pharmacy computer system to alert pharmacists that there is a duplication, and minimizing interruptions to promote workflow.

The results of the countermeasure efforts were successful. In a 4-month period, the number of duplications was reduced from 10 to 1. “Success was achieved by using a structured problem-solving process, involving the staff who do the work, [and] considering all the steps in the medication use process” in addition to education, new technology, and changing workflow, said Saine.

Building teams

“It’s been proven that [teamwork] can improve our patient safety, reduce our clinical errors, [and] improve patient outcomes and overall patient satisfaction,” said Julia Gannon, BSPharm, US Army MEDDAC, Heidelberg, Germany. To bolster teamwork, Gannon recently implemented a program called TeamSTEPPS (Strategies & Tools to Enhance Performance & Patient Safety) from the Agency for Healthcare Research and Quality (AHRQ).

In the TeamSTEPPS program, everyone has a shared mental model or the same goal, noted Gannon. There are three basic communication tools: briefs, which involve planning; huddles, which focus on problem solving; and debriefs, in which participants discuss process improvement.

When communicating among team members, useful feedback is timely, respectful, specific, and directed toward improvement. Gannon also highlighted conflict resolution options and information exchange strategies.

In safety, everyone should “consider taking the road to do the harder right than the easier wrong,” Gannon concluded. For more information about TeamSTEPPS, visit

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