Download Reduction of medication errors in a department of Medicine

Reduction of medication errors in a department of Medicine
Project participants: Ms. Pnina Sharon, RN, Mgr. Lenna Rothfeld and Prof. Arieh Ben-Yehuda
Background: Medications errors are major threat to patient safety
in hospital wards, for which awareness is a first essential step to
prevention.1
Methods: A safety initiative by department Head, Prof. Arieh BenYehuda and the Head Nurse, Ms. Pnina Sharon, began in 2001 with a
systematic documentation of medication errors, with special focus on
discharge summaries, local intervention on processes and periodic
reevaluation.
Results: The completeness of orders details (such as date, timing,
clear dosage and usage of capital letters for drug names) rose from 37%
adherence to guidelines in year 2001 to 59% in 2002 and 88% in 2004.
Using simple interventions such as double-check of physician’s orders by
nurses on the night shift and feedback to physicians, a four-fold decrease
of errors was documented over three years,
Conclusion & future plan: Leadership is effective in promoting a
culture of safety and reducing errors and may be a critical step for
improving safety at the microsystem level.2 Diffusion of this example to
other wards is being encouraged by presentations to department heads.
1
Kohn LT, Corrigan J, Donaldson MS. To err is human : building a safer health system Washington,
D.C.: National Academy Press; 2000.
2
Leape LL, Berwick DM. Five Years After To Err Is Human: What Have We Learned? JAMA.
2005;293(19):2384-2390.