QUALITY
IMPROVEMENT INITIATIVES
Project Name: Brattleboro Memorial Hospital
Patient Safety Initiative:
Medication Safety
Time Frame: FY 2007 and ongoing
Aim Statement: Brattleboro Memorial
Hospital endeavors to improve outcomes and ensure
the quality of care for our patients. It is our
goal to provide safe, quality evidence-based care
to our patients along the continuum of care. Performance
Improvement is a process that assists in identifying
opportunities for improvement, developing action
plans, implementing these action plans and positively
impacting patient care. An opportunity to positively
impact patient safety and quality of care is in
review of high risk processes like medication
administration. Brattleboro Memorial Hospital’s
goal is to continuously review and improve our
processes to insure safe, efficient quality care.
Description: Brattleboro Memorial
Hospital reviewed the medication process from
physician writing the medication order through
administration of the medication to identify opportunities
for improvement. BMH reviewed industry standards
to identify best practices to implement at BMH.
Interventions:
The following are interventions put into place
in FY 2007 to insure medication safety at BMH:
- The integration of the pharmacy system with
the Hospital Information System: this will assist
in the seamless transfer of information between
bed-side clinicians and pharmacy
- The installation of new locked medication
storage units in all areas, most with electronic
locks and audit trail capability to maintain
efficient workflow while insuring medication
security and safety.
- Investigation of “near miss”
(interrupted) medication error reporting throughout
the hospital identified opportunity for improvement.
It was discovered an error was interrupted involving
two pain medications with similar names. A color
coding process was implemented for these medications.
- Pharmacy developed a system where all medication
areas are inspected by a member of the pharmacy
team on a specific schedule and medications
close to expiration date are discarded. Provides
for an additional check and balance system.
Nursing and pharmacy inspect stock medication
and medication storage areas, these areas are
included in the safety rounds conducted at the
hospital
- The process of reviewing medications that
a patient is taking prior to hospitalization
is a topic discussed at medication safety. BMH’s
aim is to capture all medications a patient
is taking to insure a complete accurate list
which is important for medical treatment plans.
Several initiatives are being explored.
- BMH has implemented, with physician involvement,
preprinted order sets to reduce potential error
from legibility, preprinted protocols to reflect
best practice, as well as an electronic medication
reference available on-line for quick access
for clinician’s reference.
Evaluation and Next Steps:
Brattleboro Memorial Hospital has not had any
instance of interrupted medication errors involving
the similar sounding pain mediations since the
color coding system was implemented. Safety rounds
have not identified any expired medication in
the stock or medication storage areas since the
check and balance of nursing and pharmacy was
implemented. BMH has begun the implementation
of electronic medication storage units to include
pharmacy review of medication administration at
the bedside. The communication of medication lists
of medications the patient is taking prior to
hospitalization to pharmacy has improved. This
insures an accurate medication list to identify
potential medication interactions as well as effect
on the medical treatment plans.
The medication safety committee will continue
to discussion and suggest performance improvement
initiatives as opportunities are identified.
Contact
Quality Management Department
Brattleboro Memorial Hospital
17 Belmont Avenue
Brattleboro, VT 05301
Mary L. Morgan
VP Quality Patient/Safety
mmorgan@bmhvt.org
802-257-8355 (phone)
802-257-8813 (fax)
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