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March 10, 2003

The Massachusetts Coalition for the Prevention of Medical Errors, together with the Massachusetts Hospital Association, is hosting a Leadership Briefing to provide hospitals’ administrative and clinical leadership information on their newest patient safety activities. The Coalition has been identifying proven safety practices and will be initiating a two-year program to promote their implementation for the following two topic areas:

Reconciling Medications: In 25-40% of patients entering the hospital, there are unintentional discrepancies between the medications prescribed on admission and those taken at home. Reconciling medication orders on admission has been shown to prevent these errors.

Communicating Critical Test Results: Delays in communicating life-threatening test results to the responsible physician are widely recognized as a serious problem. These delays are reported for laboratory, radiology, cardiology and other diagnostic tests in inpatient and outpatient settings. The potential for impact is great; in one study the mortality rate of patients with critical test results was reduced by half, from 13% in the control group to 7% in an intervention group for whom an alerting system had been put in place.

Consensus Groups from each project have identified practices based on the literature and national models to address these clinical problems and reduce related errors. The Coalition will be offering collaborative learning opportunities and other support to facilitate the implementation of these practices.

We expect these initiatives to be of value for hospital improvement efforts for the following reasons:

  1. Resonance with clinicians: Physicians, nurses, pharmacists, laboratory personnel and other clinicians from many practice sites confirm that these projects are clinically important problems; the topics were selected by hospital representatives.
  2. Data driven: The prevalence of errors with harm is well-documented.
  3. Evidence of success: Implementation of these practices has already demonstrated gains in patient safety; Massachusetts hospitals offer success stories and local expertise.
  4. Efficiencies: These projects do not require substantial initial investments; savings can be achieved from efficiency gains for clinicians and reductions in adverse events.
  5. Support: There will be many supports for hospital teams, including two collaboratives, implementation tools, and follow-up support.
  6. Broadened focus: The Coalition’s broad constituency will allow promotional activities addressing solutions outside the hospital setting including public education programs and outreach to physician office practices.
We hope all Massachusetts hospitals will find implementing these two practices appealing because of both their power to improve safety and the support we will provide to make implementation easier. National experts will present each practice, fellow Massachusetts CEOs will discuss their perspectives, and we will describe the staff and time that would be necessary for a hospital to participate in the initiative.

These projects have been funded with a grant from the Agency for Healthcare Research and Quality (AHRQ) through the Massachusetts Department of Public Health. If you have questions, please contact Paula Griswold at 781.272.8000 x 152.

Support for Hospitals Implementing Safe Practices for Reconciling Medications and Critical Test Reporting
  1. Detailed definitions of the identified safe practices. These are the specifics about what is included in each practice – the essential ingredients. These have been developed by Consensus Groups of our local experts.
  2. Strategies for successful implementation, reflecting the experience of our Massachusetts teams.
  3. Statewide collaboratives. These will be run by the experts and will be available to teams from all Massachusetts hospitals at minimal cost. We anticipate having two meetings a year for improvement teams. At these meetings we will provide specific implementation guidance, presentations by experts and hospital teams that have successfully adopted the recommended strategies, and networking opportunities.
  4. Implementation worksheets to assist in identifying planning needs, projected tasks and timelines, and spreadsheets for estimating required resource utilization and long-term benefits from error reduction and workflow efficiencies.
  5. Toolkits to support implementation including sample forms, policies and procedures, measurement protocols, risk assessment tools (process flow charts, FMEA examples), staff and patient education materials, case studies with examples of cycles of change, and copies of research articles.
  6. Accreditation support including worksheets and examples to support utilization of this activity for JCAHO and MHQP and other payer reporting requirements.
  7. Networking and follow-up support through status reporting and opportunities for consultation with other healthcare providers engaged in specific implementation components and listserv interest groups.
  8. Public campaign to promote consumer awareness and patient education and support enhanced opportunities to partner with patients and families.
  9. Outreach to caregivers in ambulatory settings (PCPs, clinics, rehab, SNFs) to address crucial information transfer issues for medications and critical test results and to improve continuity of care.

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