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Medication Safety Program in an Integrated Health-Care System

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
Norfolk, Virginia



This report describes a comprehensive medication safety program developed over a five-year period in a six-hospital integrated health-care system.

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.

Selected References

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.