A Journey of Safe Medication Practice

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In the fall of 1999, Etobicoke General, Georgetown District Memorial and Peel Memorial Hospital amalgamated to become the sixth largest hospital in Ontario, William Osler Health Centre. The amalgamation offered an opportunity for all sites to review their current practices regarding medication policies, procedures and systems so that a new evidence-based corporate approach could be developed. This tri-hospital connection laid the foundation of readiness for staff to expect many changes, especially around the area of medication delivery. We soon agreed that the overriding approach to the new system would be to create a “Culture of Safety” for medication administration.

A corporate Safe Medication Practice Committee was formed with representatives from senior administration, a representative from the physician group, managers, educators, staff nurses and pharmacy staff. The “culture of safety” philosophy was used to analyze our existing processes and practices. The focus shifted to the role played by our systems, as opposed to our people, in how errors were made. The initial work of the Safe Medication Practice Committee included various strategies to market the message of a “culture of safety” and related activities that would support the culture shift throughout the organization.

Historically, within the field of health care, a punitive approach was used when handling medication errors. The focus had been a “blame and train” attitude. Past practice had been to find who committed the error and re-educate or, after repeated errors, dismiss the individual. It was highly unlikely that such a strategy would encourage staff to disclose errors or near misses. This practice made it difficult to find the cause of errors. The logical step was to move to a non-punitive approach to the reporting and management of medication errors. Labels around medication errors began to shift overnight. Phrases such as “from error to safety” began to spring up across the organization. No longer were medication incidents referred to as “medication errors” but instead, “medication occurrences”. The awareness campaign resulted in root cause analysis of these occurrences to solve discrepancies. Reporting of near misses also increased. Near misses are defined, as an incidence where there is an error detected in the system but the error has not reached the patient. Risks in the system were identified. With this focus on prevention, a continuous quality improvement approach was taken and continues today.

Changing a culture takes time. The goal in all methods used to create awareness was to involve the key groups most directly involved in the medication system and prompt them to be part of the solution. Patient Care Managers attended a workshop where the “Beyond Blame” video (Bridge Medical Incorporated) was used to underscore risk and responsibility. The utilization of actual medication occurrence case studies assisted managers to identify potential causes and contributing factors. They were then encouraged to develop non-punitive action plans to prevent re-occurrences. Safe Medication Squads began to spring up on the patient care units, spearheaded by the staff nurses and their managers to discuss possible sources of occurrences and ways to prevent them. Safe medication practice terminology and approaches were incorporated into new staff orientation. Educators and pharmacists were encouraged to include a safe medication practice approach in their inservices, protocol development and consultant activities.

A member of the Safe Medication Practice Committee consulted with physician focus groups to obtain their perceptions of safe medication practice and to identify the medication system risks they are currently experiencing in their practice. Physicians also acknowledged their part in the process with incomplete orders or illegible orders and they encouraged the use of a computer Prescriber Order Entry system.

Endorsement from the Board and senior administrative staff has promoted safe medication practice across the corporation. This resulted in the purchase of an Automated Medication Delivery system to be installed on the nursing units. Early projections foresee the reduction of medication occurrences by as much as 33 per cent. In the long run, 70 per cent of the current occurrences could be decreased by the new dispensing units. There is controlled access and the streamlining of the medication process makes a more efficient tracking system.

Drug misadventures related to the use of intravenous Potassium Chloride can have dramatic consequences. Widespread accessibility to Potassium Chloride concentrate polyamps on patient care areas has been identified as a key potential for error. Last June, 2002 the corporation introduced pre-mixed Potassium Chloride intravenous solutions. An automatic substitution policy was also implemented for physicians who did not order the standard premixed solutions. The goal on implementation was 80 per cent of all orders being standard. Three months after implementation, we are excited to report that 90 per cent of orders comply with the use of standardized pre-mixed Potassium Chloride solutions and Potassium Chloride Amps have been removed from most patient care areas. The Ontario Hospital Association has recently announced a focused strategy to assist all hospitals with creating safe practices regarding intravenous Potassium Chloride.

The introduction of new medication products is also a contributing factor for error. A “New Product Team” has been established to link with the purchasing agents so that potential error concerns are incorporated in purchasing decisions. The team alerts the Pharmacy Nursing Liaison Committee who, in turn communicates with educators to alert their unit staff. This proactive approach to increase awareness of similarity of products or labelling has reduced errors.

The awareness campaign at William Osler Health Centre to embrace and function within this “Culture of Safety” philosophy has met with great success. Individuals are more likely to act when others around them participate in achieving the same goal. Health care professionals continue to be accountable for their own actions, but the system encourages openness. Sharing failures prevent future occurrences. The focus is taken off the individual and put on the system.