March 10, 2003
ON STATEWIDE PATIENT SAFETY INITIATIVES
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
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:
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.
- 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
- Data driven: The prevalence of errors with harm is well-documented.
- Evidence of success: Implementation of these practices has already
demonstrated gains in patient safety; Massachusetts hospitals offer success
stories and local expertise.
- Efficiencies: These projects do not require substantial initial investments;
savings can be achieved from efficiency gains for clinicians and reductions
in adverse events.
- Support: There will be many supports for hospital teams, including
two collaboratives, implementation tools, and follow-up support.
- 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.
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
Support for Hospitals Implementing Safe Practices for
Reconciling Medications and Critical Test Reporting
- 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
- Strategies for successful implementation, reflecting the experience
of our Massachusetts teams.
- 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.
- 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
- 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.
- Accreditation support including worksheets and examples to support
utilization of this activity for JCAHO and MHQP and other payer reporting
- 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.
- Public campaign to promote consumer awareness and patient education
and support enhanced opportunities to partner with patients and families.
- 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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