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A Roadmap for Award-Winning Pharmaceutical Safety Practices

February 01, 2017

The Institute for Safe Medication Practices (ISMP) recently awarded its annual “Cheers Award” to Ascension Health for or its comprehensive implementation of the 2014-2015 ISMP Targeted Medication Safety Best Practices for Hospitals, which included use of a weekly dosage regimen default for oral methotrexate and the recommendation to record the body weight of patients in metric units only. Roy Guharov, PharmD, MBA, the chief pharmacy officer for Ascension, accepted the award on behalf of the health system. He was proud to be recognized, but said he was merely representing the incredible amount of teamwork among pharmacists, nurses, physicians, and executives that made the achievement possible. Dr. Guharov recently shared the inside scoop on Ascension’s award-winning ways, including why a seemingly small process improvement tipped the scales in the health system’s favor.

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What inspired your team to focus on the ISMP's best practices?

The recommendations were in response to adverse drug events that had occurred in hospitals across the country over the previous decade, so we embraced the system-wide implementation of processes to protect our patients from medication-related harm. Our health system’s senior executives were fully supportive of the plan we proposed, which involved the efforts of a multi-disciplinary team of pharmacists, nurses, and physicians. They reviewed the ISMP’s best practices and told us to make sure they get implemented in all of Ascension’s hospitals over the course of 12 months.

Which best practice was the most challenging to implement?

Making sure that patients’ weights were always recorded in kilograms at the time of admission was a big challenge for us, because the scales we had in use at the time measured weight only in pounds or in both pounds and kilograms, which led to the wrong documentation in medical records. Getting the accurate weight of every patient upon admission is critically important. If that weight is wrong or mixed up between pounds and kilograms, under- or overdosing can occur. We looked at our health-system’s database and found that quite a few adverse drug events were caused when patients got the incorrect amount of a drug because an inaccurate weight was inputted in the health-system’s electronic health record. We’ve now standardized the process so all patients have their weight measured in kilograms. It was a more involved fix than you might think when you consider we had to implement the change by adding metric scales and updating how weight values were inputted into electronic health records across 141 hospitals.

How did monthly coaching calls contribute to the successful rollout of the best practices?

The coaching calls promoted teamwork and were extremely helpful in getting the medication safety practices implemented efficiently and effectively. We received support from quality improvement committees and health-system administrators, but needed to communicate our medication safety improvement efforts to the front lines of care. Medication safety is not a pharmacy issue or a physician issue — everyone has to be involved. The monthly coaching calls brought together physician leaders, pharmacy directors, and chief quality officers from each of the health-system’s hospitals for reviews of how implementation of the best practices was progressing. Leaders from hospitals that had made progress on a particular medication safety goal would present their methods for success to the rest of the group. The involvement of various stakeholders and the sharing of ideas were keys to getting the recommendations implemented across the health system.

Can you share an instance when one of the best practices prevented a medication error from occurring?

Methotrexate is a drug typically dosed daily to treat cancer, but it can also be used once a week as an immunosuppressant to treat, for example, psoriasis. We implemented a hard stop in our electronic medication ordering system so that pharmacists must verify once-daily prescriptions for methotrexate before the order is processed. On one occasion, a pharmacist intervened and checked with the prescribing physician, who said the prescription was intended for a patient with psoriasis and shouldn’t be used daily. The dose regimen in the order was changed to once a week, and the patient was saved from experiencing the severe adverse events associated with the drug.

What role should pharmacists play in getting frontline providers to improve safe medication practices?

Pharmacists are the drug experts and they must champion safety processes to prevent patients from harm. They must be transparent by sharing near misses or serious adverse events, the lessons learned from them, and the associated actions needed to prevent similar errors from reoccurring. Pharmacists must be actively involved in improving drug ordering and delivery processes, but can’t do the job alone. They must team with physicians, nurses, and executives to understand the entire medication management chain, from prescribing to administration, in order to identify gaps and fix potential issues.

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