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Hospital Implementing Medication Event Huddles Reduces Adverse Drug Events

Added on December 19, 2013 in General News, Press Releases

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(Oak Brook, Ill.) Today, Joint Commission Resources announced the release of the January 2014 issue of “The Joint Commission Journal on Quality and Patient Safety,” featuring an article on how a hospital that implemented medication event huddles dramatically reduced the incidence of adverse drug events (ADEs).

As described by Shelly Morvay, PharmD, and her co-authors in “Medication Event Huddles: A Tool for Reducing Adverse Drug Events,” Nationwide Children’s Hospital (NCH), Columbus, Ohio, conducted more than 800 medication event huddles over three years, thereby identifying more than 3,000 improvements. ADEs, defined as injuries resulting from medical care involving medication use, accounted for approximately two thirds of reported patient harm at NCH.  

The quick-investigation huddle tool was proposed as a means to engage frontline staff in identifying process improvements that might contribute to ADE elimination. In March 2010, NCH piloted the medication event huddle process in its critical care units, and in 2011, introduced the process to all inpatient units and some ambulatory clinics. Subsequently, NCH has spread the process to ADEs that occur anywhere in the organization, including all ambulatory clinics, the emergency department, perioperative areas and interventional radiology.

The 30-minute medication event huddles were initiated and scheduled within 24 hours whenever an ADE was identified, and included:

  • An explanation by the core huddle team leader of the huddle process;
  • Simulation of the ADE using the actual electronic medical record, infusion pump, pharmacy labels and other equipment or supplies;
  • Review of a standard list of questions to identify environmental or practice factors that may have contributed;
  • Assignment of identified interventions or “tests of change” to appropriate participants;
  • Follow-up communication about “tests of change” via email; and 
  • Encouragement to speak with colleagues about the specific ADE and huddle experience.

In addition, the medication event huddles were used as an opportunity to promote a culture of safety, increase involvement of frontline staff and speed improvement efforts. Findings showed that the absolute number of harmful ADEs decreased by 74 percent, and the ADE rate per 1,000 dispensed doses decreased by 85 percent.

The authors stated that medication event huddles require a minimum of 0.5 full-time-equivalent nurses to review the ADEs, schedule the huddles and follow-up on completion of recommendations. While huddles do not replace a formal root cause analysis or daily safety walkarounds by leadership, they do enable a more rapid identification of the cause and subsequent intervention.

“The Joint Commission Journal on Quality and Patient Safety,” published monthly by Joint Commission Resources, is a peer-reviewed journal, available by subscription, which serves as a forum for practical approaches to improving quality and safety in health care.

Methods, Tools and Strategies

Sustainable, Effective Implementation of a Surgical Preprocedural Checklist: An “Attestation” Format for All Operating Team Members
Allison J. Porter, MD; Jon Y. Narimasu, MD; Michael F. Mulroy, MD; Richard P. Koehler, MD

Adoption of a preprocedural pause or time-out associated with a checklist and a team briefing improves teamwork function in operating rooms (ORs) and results in improved outcomes. At Virginia Mason Medical Center, where a surgeon-led pause revealed completion of all items in only 54% of the cases, a new preprocedural checklist format, which requires participation by all operating team members, led to 97% completion. Use of the attestation format has been extended beyond ORs—for use in interventional radiology, gastroenterology, and electrophysiology suites.  

Using a Virtual Breakthrough Series Collaborative to Reduce Postoperative Respiratory Failure in 16 Veterans Health Administration Hospitals
Lisa Zubkoff, Ph.D.; Julia Neily, RN, M.S., M.P.H.; Peter D. Mills, Ph.D., M.S.; Ann Borzecki, M.D., M.P.H.; Marlena Shin, J.D., M.P.H.; Marilyn M. Lynn, NP, M.S.N.; William Gunnar, M.D., J.D.; Amy Rosen, Ph.D.

A Virtual Breakthrough Series quality improvement collaborative, which employed distance learning, helped teams at 16 Veterans Health Administration hospitals implement multiple evidence-based interventions (organized by care processes) to help reduce postoperative respiratory complications. Eleven conference calls were conducted, each focused on a topic, such as “Using Data to Evaluate Improvements to Prevent Postoperative Respiratory Failure” and “Holding the Gains and Spreading.” The virtual (versus the traditional face-to-face) collaborative was an efficient method for reaching and linking multiple sites in a collaborative effort to improve care.

Teamwork and Communications

Eight Critical Factors in Creating and Implmentating a Successful Simulation Program
Elizabeth H. Lazzara, Ph.D.; Lauren E. Benishek; Aaron S. Dietz, M.A.; Eduardo Salas, Ph.D.; David J. Adriansen, Ed.D., NREMT

Given the risks inherent in learning new skills or advancing underdeveloped skills on actual patients, simulation-based training (SBT) has become an invaluable tool in medical education. The simulation, training, and learning literature was used to provide a heuristic of the important facets of simulation program creation and implementation, as represented by eight critical “S” factors—science, staff, supplies, space, support, systems, success, and sustainability.

Operations Management

“Not So Fast!” The Complexity of Attempting to Decrease Door-to-Floor Time for Emergency Department Admissions 
Gene R. Quinn, M.D., M.S.; Elizabeth Le, M.D.; Krishan Soni, M.D., M.B.A.; Gabrielle Berger, M.D.; Y. Erica Mak, M.D.; Read Pierce, M.D.

Successful quality improvement, which is fundamental to high-performing health care systems, becomes increasingly difficult as systems become more complex. A study of unsuccessful attempts at University of California, San Francisco Medical Center to reduce door-to-floor (D2F) time in the emergency department suggests that three domains—(1) Improving Work Flow, (2) Changing Culture, and (3) Understanding Incentives—are important sources of resistance and opportunity.


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