Mutter Michael
Clinical Systems and Quality Improvement, Valley Hospital, Ridgewood, New Jersey, USA.
Jt Comm J Qual Saf. 2003 Jun;29(6):279-88. doi: 10.1016/s1549-3741(03)29032-8.
The Valley Hospital, a 451-bed acute care facility in Ridgewood, New Jersey, has made substantial progress in the reduction of medication administration errors.
Reduction in medication administration errors were accomplished through (1) becoming intimately familiar with the errors, including where, when, why, and how they were occurring; (2) establishing a nonpunitive environment and encouraging reporting of errors, including near-miss errors; (3) trending error report data to identify areas of concentrated errors in the medication use process; (4) simplifying and standardizing process steps; and (5) selecting the right technology to address error-prone steps in the hospital's systems.
The establishment of a nonpunitive environment led to a dramatic increase in the number of nearmiss errors reported, and the information gained proved to be valuable and diagnostic. Establishing an interview process with the caregivers directly involved in occurrences enabled us to gather detailed information about errors. This forum led the way to an early understanding of human factors, system failures, and root cause analysis. Those errors were trended, addressed, and reduced through manual system changes and technological system developments designed to ensure the "five rights" of safe medication administration.
Keeping on course requires constant and continuous review of medication use processes to ensure that they support instead of unnecessarily limit actual practices.
