Medication Safety Program in an Integrated
Rhonda Liberto, Pharm.D., Dave Merryfield, B.S. Pharm.,
Timothy S. Jennings, Pharm.D., Mark Szalwinski, M.H.A., R.Ph.,
Gary Yates, M.D.
Sentara Healthcare System
This report describes a comprehensive medication safety program
developed over a five-year period in a six-hospital integrated
Description of the Program
The ongoing medication safety program commenced with several
analysis activities: self-evaluation process recommended by
the Institute for Safe Medication Practices (ISMP); replication
of the Bates and Leape observational study for medication
errors; multidisciplinary evaluation of our medication adverse
event reporting data; and evaluation of our medication systems
using a high risk drug matrix (HRDM) based on Cohen’s
recommendations, including 18 categories of highest risk medications.
These analyses confirmed results reported in the literature
concerning typical sources of errors in medication administration.
Senior leadership committed to making safety initiatives the
primary priority for the system, leading to decisions to dedicate
both personnel and technology resources to address the problems.
A position for a medication safety clinical pharmacist was
implemented in June 2001. In August 2001, clinical screening
and alerting technology was implemented, and lab interface
was added in July 2002.
In March 2002, a review of trigger tool data for system-wide
adverse drug events (ADEs) showed that most ADE triggers were
associated with anticoagulation (11.5%) and over-sedation
related to pain management (15.7%). Additionally, 27% of the
ADEs resulting in serious or severe outcomes or death (termed
serious hereafter) in 2001 were related to anticoagulation,
and 16% were related to oversedation. Based on these data,
we established a goal to reduce the number of adverse drug
events, especially those related to anticoagulation and oversedation
related to pain management.
Our first step to achieve multidisciplinary practice changes
was changing the structure of the medication use safety improvement
committee (MUSIC) from a single system-wide committee into
an executive MUSIC and individual hospital MUSICs, thereby
providing a medication safety focus at leadership and grassroots
levels. Executive MUSIC clears barriers, motivates, and steers
the focus of the local MUSICs and the medication safety clinical
pharmacist. Local MUSICs with staff involvement have most
of the responsibility for implementation.
A multifaceted approach was envisioned to evaluate, guide,
and monitor our progress. While we used innovative approaches
to nationally recognized recommendations and tools, the basics
are widely available. For example, building on the HRDM recommendation
of close observation and vital sign monitoring, a task force
of nursing and pharmacy staff members substantially revised
the methods for monitoring patients receiving narcotics or
sedatives. All narcotics would require pain and sedation scores
with one-hour follow up, and sedating agents would require
a sedation score. In addition, in parallel with the work of
the medication safety clinical pharmacist and MUSIC, clinical
screening and alerting technology provided more tools for
improving medication safety. We currently have more than 300
alerts in operation. These focus primarily on safety with
anticoagulants and pain management, including ISMP best practices
and lab monitoring.
Experience with the Program
Overall, serious ADEs declined from 51 in 2001 to 28 and 11
in 2002 and 2003, respectively; none were reported for the
first quarter of 2004. Anticoagulant ADEs decreased by 39%,
from 23 to 14. The number of warfarin ADEs resulting in substantial
patient harm decreased by 45%. Serious ADEs resulting from
oversedation declined by 50% from eight in 2001 to four in
2003, with none during the first quarter of 2004.
The sustained success of our medication safety program can
be attributed to our comprehensive approach involving a firm
commitment to medication safety, the willingness to engage
everyone from senior leaders to frontline staff in the process,
the pursuit of multiple strategies in parallel, and a clear
linkage to the overall goal of patient safety.
1. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis
of adverse drug events. JAMA 1995; 274: 35-43.
2. Cohen MR, ed. Medication errors. Washington DC: American
Pharmaceutical Association; 1999.