Medication Safety Week Reflections: I Am Medication Safety

Many young children have a favorite item that brings them comfort—often a cozy blanket, stuffed animal, or doll of some sort. My 7-year-old daughter Meredith is one of those children.

Puppydog is Meredith’s stuffed golden Labrador and has been her best friend and protector for most of her life.

Nervous about flying on an airplane? Puppydog will help you with your seatbelt.

Worried about monsters under your bed? Puppydog will keep watch all night long.

Meredith, 7, with her best friend and protector Puppydog.

Puppydog will even get his nose swabbed for COVID-19 just like you. Nothing can go wrong when Puppydog is by our side.

What does a girl and her stuffy have to do with patient safety? Everything. For many, being in the hospital is equivalent to how Meredith feels during times of uncertainty. Everyone wants to know that someone will look out for them and keep them safe during these times. For this, hospitals have teams dedicated to patient safety that focus on everything from fall prevention to safe medication use.

The Medication Safety Team at Novant Health serves as crucial conduits between pharmacy, risk management, and patient safety across the entire health system. The team is composed of three pharmacists who aim to reduce preventable medication-related patient harm to zero. Learn more about the Novant Health Medication Safety Program and our work to support patient safety below.

Safety Surveillance

Across Novant Health, data are used to drive decisions, and that’s no different for the Medication Safety Team. With the support of a dedicated business analysist, the team compiles key metrics in dashboards customized for each care area (acute care, specialty pharmacy, ambulatory care, oncology).

These metrics include information from our voluntary error reporting system (overall reporting volume, % reported events with harm) and other assistive technologies, such as barcode medication administration (BCMA) and smart infusion pumps. Other dashboards on deck to go live in 2023 include those that incorporate “trigger” metrics pulled from the medical record and data from pharmacy production technologies, such as Dispense Prep.

Response to Internal Risk

We use data within our dashboards to proactively identify areas of risk—where we can target our efforts to make the largest impact for our patients. We look at the data from multiple angles, including care area, medication involved, and phase of the medication-use process where the risk is most prevalent.

For example, in 2022, the medication most implicated in our medication error reports was continuous IV heparin infusion used to treat thrombolytic conditions. Our analysis of voluntary event reports showed several issues with the technology nurses used to calculate rate changes for this medication.

The Medication Safety Team escalated these concerns, along with recommendations to improve processes, to our information technology colleagues. As a result, calculator changes to address the identified issues are scheduled to go live soon.

Response to External Risk

The Medication Safety Team also monitors external sources for safety risk, assessing whether there is potential for such risk within Novant Health. Like many hospitals and health systems, we learned important lessons from the 2017 error involving the use of a paralytic medication at Vanderbilt University Medical Center. As a result, we changed the way our own high alert medications were stored within automated dispensing cabinets and removed medications such as neuromuscular blockers from areas without demonstrated clinical need. In addition, safety alerts from organizations such as the Institute for Safe Medication Practices and The Joint Commission are reviewed and escalated by the team and risk mitigation strategies are implemented across the health system.

Building a Better Safety Culture

Perhaps one of the most important responsibilities of the Novant Health Medication Safety Team is our charge to build a better safety culture. We can’t act on risk that we don’t know exists, and so we rely on our team members to “bark” (to borrow a trick from Puppydog) in the face of trouble or uncertainty to show us where that risk lies.

We train our team leaders in the art of storytelling—that is, sharing safety events that have happened or nearly occurred to learn lessons about preventing a similar event in the future. Through our Great Catch Program, we also celebrate our team members when they prevent errors from reaching patients and recognize the greatest of the great through pur annual Home Run award.

I like to think that our team has a lot in common with Puppydog—we’re small but our impact is substantial.

Need help avoiding a look-alike, sound-alike error? The Medication Safety Team will help you design strategies to minimize risk.

Looking for advice on how to support a team member involved in a medication error? The Medication Safety Team will help you review the error focusing on just culture.

Just like Puppydog means the world to Meredith, as safety professionals, we know our diligence means the world to our patients. And as health care providers, so can yours. You can give them comfort as they face the unknown and be their protectors and defenders by keeping them safe from medication misadventures. Happy Medication Safety Week! YOU are medication safety.