By making six changes over nine months to its medication safety practices, Metropolitan Hospital in Grand Rapids, Mich., last year was awarded the Institute for Health Care Improvement's five-star rating. Here's what Metro did to earn its best-in-the-nation nod.

1 Re-think your reporting system
The first thing Metropolitan did was establish a non-punitive reporting environment to encourage disclosure of medication errors and near-misses. Nurses and techs are free to report potentially dangerous situations without fear of reprisal.

"The literature shows that if a medical error is made, and the person who reports it risks being reprimanded, it significantly drives reporting down," says Pete Haverkamp, RPh, the hospital's director of pharmacy services. "The change to a non-punitive system has increased reporting dramatically; we now get an average of 300 reports to 600 reports of potential safety situations per month."

2 Put tools at staff's disposal
Anything you can do to make it easier for staff to do the right things and make the right decisions is good. Metro developed and distributed to physicians and nurses pocket cards that list unacceptable medication abbreviations and documentation standards. The index-sized cards were compiled and produced in-house by Regina Ricketts, the head of Metro's quality improvement department, based on the Joint Commission's and Institute for Safe Medication Practices' lists of confusing abbreviations, such as writing "U" instead of "unit" and "'g" for "micrograms."

The problem, says Mr. Haverkamp, is that such abbreviations, when hand-written, can be easily misread or misinterpreted. For example, when a "U" is hand-written, it can sometimes look like a zero. In addition, staff are instructed to use leading but not trailing zeroes. That's because, if the decimal point is missed (by either the writer or the reader), it can result in a tenfold dosing error, says Mr. Haverkamp. The quick-reference cards help prevent that.

3 Use medication dispensers
Metropolitan installed automatic medication-dispensing machines to limit access to high-risk medications. Among the features of the machines: required passwords; automatic charges to patients; medication instructions displayed on a screen; and double-checks on drugs with sound-alike names, such as hydromorphone and morphine.

To help nurses quickly learn how to use the medication dispenser, the manufacturer did an in-service in which it put candy in each drawer in the machine; if nurses successfully completed the tutorial, they were able to access the candy.

"The machine was depleted very quickly," says Donna Rudy, MSNH, RN, Metropolitan's surgical services director. "OR people love to eat."

"Nurses were a little skeptical at first about it slowing us down," says Karen Middendorf, RN, BSN, Metro's clinical coordinator. But when nurses realized the machine did much of the medication charting work they were responsible for, made safety catches and actually saved some time, "people who had been resistant started to love it," she says.

Nurses no longer have to perform shift-end narcotics counts. "Pharmacy doesn't have to bother nurses to do paperwork; it's all automated," says Mr. Haverkamp. "We know when we have to do a narcotic reorder because the machine records everything for us."

Plus, says Ms. Middendorf, "Inevitably, once in a while, someone would go home with one of the keys, delaying the shift count while we waited for them to return."

The automation has let Metropolitan "institute quality measures regarding antibiotics and surgical times, put meds in the PACU, and pharmacists, physicians and nurses confirm that drugs are immediately available for use," says Mr. Haverkamp. "We know when a drug was used, who it was used on and how it was given. We've improved our ability to get patients the right drugs at the right time."

Best of all, says Ms. Rudy, Metro expects to recapture $7,000 to $12,000 a month in lost medication charges.

4 Simplify processes
Metro also consolidated patient allergy records onto a single form within each patient's medical records. Previously, nurses, physicians and anesthesiologists recorded patient allergies by hand - all over the patients' medical records.

"Every med order had to be recopied from and onto anesthesia records, surgical records and the nurse assessment form," says Mr. Haverkamp. "That almost guaranteed that info in one section wouldn't match another."

Now, it's all on one electronic form that a nurse goes over with the patient upon admission. When the patient is admitted, the automated system instantly populates with any allergies on file. When it is printed and placed in the file, staff need only look at the one allergy assessment page.

"Patients don't always remember to tell you every allergy with each admission or to each person they talk to," says Ms. Middendorf.

"We now get an idea what they told us last time and increase the quality and accuracy of the information we're gathering," says Mr. Haverkamp. "It used to be a treasure hunt. Now it's centralized and standardized, which saves everyone a ton of time and phone calls."

5 Revise medication standards
Oftentimes, drugs weren't listed or abbreviated consistently in patient charts, on physicians orders and elsewhere, leading to interpretation issues for nurses and pharmacy staff, says Mr. Haverkamp. So a medication-use committee worked to revise the standards for ordering and administering medication. The result: preprinted forms that let physicians simply check boxes for the drugs they want patients to receive.

"We involved a lot of physicians across disciplines to find out variables such as how meds are ordered and what each physician's standing orders looked like," says Mr. Haverkamp. "We were able to come up with a set of forms that worked for everyone."

The next step, he says, is to computerize this ordering: "We're just beginning to try online orders, which will let surgeons type right into the computer and send the order directly to the pharmacy."

6 Implement medication reconciliation forms
These forms, to be used at time of admission, ensure patients take the same medication in the hospital as at home. To do this, you should assign someone to work with the admitting physician or the patient's primary care physician ahead of time to confirm each patient's prescription medications.

"The outpatient nurses get medication information from the patient in the pre-anesthesia interview regarding what meds they take, the dosage, etcetera, and we tell them what to take the day before and day of surgery," says Lisa Schuel, RN, BSN, the director of the outpatient surgery and PACU units at Metro. "We give that information to the anesthesiologist so that if, say, a patient's blood pressure is high, we'll know he took his anti-hypertensives, and he can make decisions based on that."

One step at a time
Metropolitan made these changes as part of a drug-safety overhaul, but you don't have to take on the daunting task of all six at once. Taking even one of these actions at your surgical facility could help improve your medication safety.