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 Medication Safety

Look in the January 2000 issue of The Quality Letter for Healthcare Leaders for
the article on our work entitled "Hospital System Tries Both Fast and
Far-Reaching Strategies to Reduce Errors."

Look in the February 2000 issue of Trustee for the article about us in "Ending
the Culture of Blame: A Look at Why Medical Errors Happen and What Needs
to Change."

We're assisting a multi-hospital system to improve medication safety by
aggressively implementing numerous best practices. The chart below shows
our progress.

Best Practice	Hosp A	Hosp B	Hosp C	Hosp D	Hosp E	Hosp F
Chemotherapy protocols and preprinted orders
Weight-based heparin protocols	Next				Piloting
Enforcement of standardized prescribing	Piloting			Piloting	Piloting ICU
Removed KCl concentrates from all units
Patient partnering						Sept. 2000
Colored patient allergy wristbands		Piloting
Limited numbers of dosages and pump types for IV solutions
Computerized drug profiling
Pharmacy-based admixture of IV solutions
Pharmacist on unit, at rounds						Piloting
Warning labels for look-alike/sound alike drugs	Next			Piloting	Piloting
ER condition management protocols
Maximum 12 hour shifts for all personnel
Critical pathways for complicated care						Sept. 2000
24-hour a day pharmacy service availability
Non-punitive error reporting

Legend:

	x	Piloting	Next
Not yet implemented	Equivalent in place; won't implement	Began pilot test	Next pilot test	Already in routine use in part of hospital	Throughout entire hospital/ Not applicable