1. New Center of Excellence Focuses on Patient Safety Research
BWH is the recipient of a Center of Excellence award from the Agency for Healthcare Research and Quality (AHRQ). One of three institutions to receive a project grant, BWH intends to build upon other hospital initiatives to improve patient safety. The Center of Excellence for Patient Safety Research and Practice's main goal is to improve medication safety across a variety of clinical settings and various patient populations through six research projects.
David W. Bates, MD, chief of General Internal Medicine at BWH is the principal investigator/program director of the Center of Excellence.
Funded through AHRQ, the Center of Excellence is headquartered and directed at BWH with collaboration from area institutions including: MGH, Harvard School of Public Health, Newton-Wellesley Hospital, Children’s Hospital, the Risk Management Foundation, McLean Hospital and UMass Medical Center. AHRQ has committed $5 million of their 2001 patient safety directed funding to support this Center over a five-year period.
The research projects will include:
- Evaluating Tools that Facilitate Reporting, Surveillance and the Analysis of Medical Errors/Adverse Events;
- Ambulatory Medication Errors and Adverse Drug Events in Pediatrics;
- Epidemiology and Prevention of Medication Errors in Psychiatric Inpatients;
- Safe Intravenous Infusion Systems;
- Improving Safety with Anticoagulation in the Nursing Home; and
- The Role of Organizational Culture in Promoting Patient Safety.
2. The Drug Safety Committee
Co-chaired by William Churchill, RPh, director of Pharmacy Services and Tejal Gandhi, MD, director of Patient Safety, the Drug Safety Committee was established at BWH in November 2000, to focus on improving the safety of the hospital’s medication use process.The committee’s charge is to proactively review the medication use process to identify system improvement opportunities that will enhance medication safety. The committee accomplishes its mission by reviewing every medication related incident report, spontaneous reported adverse drug reaction reports, and using data obtained from the computerized adverse drug event screening tool. The data are reviewed to identify system improvement opportunities.
In addition, the committee focuses considerable attention on reviewing physician order sets, reviews and updates Drug Administration Guidelines, and reviews requests from clinical services to add or delete medications from the SureMED override list. Committee members also review national trends on adverse drug reporting and monitoring of medication errors. This data is routinely compared to BWH specific data.The committee membership is comprised of pharmacists, physicians, nurses, and representatives from Risk Management, Patient Safety and Information Systems.
Some of the accomplishments of the committee to date include:
- Enhancements to the Patient Order Entry System (POES) for high risk medications;
- Clarified dosing/abbreviations for KCL, Mg and Insulin scales in POES and the ED POES;
- Standardizing the heparin continuous infusion to one concentration;
- Listed the ml/hr as well as units/hr for heparin in the POES template;
- Implementation of the Adverse Drug Event Monitor: Proactive review of potential errors based on sets of "rules" where medication orders are linked with real time lab orders to detect potential adverse events (the pharmacists review these alerts and suggest alternatives to the physicians);
- Medication Error and Adverse Drug Event dashboard reporting to the nursing and medical leadership of each Care Improvement Team;
- Review and modification of all physician order sets in BICS; and
- Review and revision of the Drug Administration Guidelines and publication of these in the CI Handbook.
If you have questions or comments, please email:
William Churchill, Tejal Gandhi, MD, or Erin Graydon-Baker.