Sim Terri A, Joyner Julie
Williamsburg Community Hospital, 301 Monticello Ave, Box 8700, Williamsburg, VA, USA.
Jt Comm J Qual Improv. 2002 Jul;28(7):403-9. doi: 10.1016/s1070-3241(02)28040-2.
In March 2000 a multidisciplinary team was formed at Williamsburg Community Hospital (Williamsburg, Virginia) to address medication-related patient safety initiatives. MEDICATION SAFETY TEAM: The team focused on promoting a nonpunitive reporting environment, developing a collaborative medication administration policy, and designing an education and communication plan that promoted safe medication practices. In creating a nonpunitive environment, the first step was to revise the medication variance reporting policy. The team focused on process improvement and removed all references to corrective action from the policy. It launched an extensive educational effort throughout the hospital to raise awareness of the change in policy and to increase the focus on patient safety initiatives. The team also oversaw development of a comprehensive medication administration policy, which consolidated nursing, physician, and pharmacy practices. The team implemented a number of quick fixes that generated momentum and provided some immediate successes.
Within a 9-month period (May 2001-January 2002), the number of reports doubled. As the number of variance reports increased, a subcommittee formed, with the specific responsibility of reviewing the reports on a weekly basis.
The team sought to change the environment and attitudes related to medication variances and reporting. This was an organization wide change that required employees to change their perceptions regarding the purpose of reporting. Implementing the changes in small bites to realize immediate successes helped provide the impetus to keep the team focused and energized in tackling this huge endeavor. The team provided the ability to solve problems and recommend changes quickly and effectively from a variety of perspectives.
