How do I Create an Organizational Culture for Medication Safety?
Instructions
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Check the systematic transfer of information at shift changes. Shift changes constitute a high risk time for medication errors because the outgoing staff is eager to leave the shift and the oncoming group is not yet up to date on the status of the patients. Systematic transfers of information--such as assigning a point person to check off patient medication updates, automated medication list updates and other methods of making information exchange more automatic--can greatly reduce change-of-shift errors.
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Create an "adverse event" response team. When medication errors happen, the team needs an immediate response oriented toward safety, improvement and prevention of future adverse events. Shifting from a culture of blame to a culture of learning from mistakes helps prevent future errors. Members of the health care team will be much more willing to provide honest information about their role in a medication error if they know that the system works toward continual improvement and learning from errors.
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Reenact real or scripted adverse medication safety events. Sometimes the best way to evaluate holes in a system is to reenact the daily processes and look for places where things can go wrong. Reenacting a real adverse event can help identify system-level weaknesses and let team members understand that mistakes are rarely just one person's fault. Simulations using scripted events based on a mixture of real events and educational modules can also make team members aware of potential medication errors before they occur.
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Identify a medication safety leader for every unit or section of the health system. Empowering staff members to lead from within makes a powerful tool for ensuring patient safety. Managers have an important role in generating a culture of safety, but front-line staff often have a better understanding of the system and its potential pitfalls. Because of this, staff often have and employ creative solutions to daily problems. Safety leaders are often responsible for conducting medication safety trainings and briefings for team members, and for soliciting safety improvement ideas. Identifying safety leaders among staff perpetuates a culture of safety at all levels of the system.
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Include patients in medication safety improvements. The more knowledge patients and their families have about medications, the less likely that errors will occur. Encouraging open communication and questions from patients and families helps create a culture of transparency and ensures that there are more eyes on the lookout for possible errors.
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Create a medication error reporting process. All members of the health care team should know and feel comfortable using a medication error reporting system. Open communication and transparency are key to improving patient safety. Systems that rely on team communication to improve care, rather than punitive reporting, are much more likely to reduce future errors.
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Identify a patient safety officer: a full-time position under optimal circumstances. Often, agencies will designate a key leader or manager at a high level in the organization to fulfill this role. The safety officer oversees all of the system safety practices to ensure continuity and accountability. Having a safety officer at an executive or other decision-making position also ensures that there is buy-in from the organization leadership.
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Ensure feedback to front-line staff. Inclusion constitutes the key component of creating a culture of safety. Front-line staff need the opportunity to voice concerns and ideas, as well as receiving feedback about their performance and what happened to their ideas. Medication safety briefings, in-person meetings, rounds or listening sessions by key leadership are all methods to close the loop on communication between all members of the health care team.
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