11 Aug Medication Reconciliation and A Culture of Safety: Do they really make a difference in patient safety?
This is the third day of the week long exploration of care transitions and medication errors. Knowing the importance and vulnerability surrounding care transitions I will present findings from the literature regarding medication reconciliation and safety culture/teamwork that will illuminate their “true” impact in reducing medication errors. For another look at how Hope Street Group conceives to improve the quality and cost of transitions between acute and other types of care see our Using Open Innovation to Reinvent Primary Care report.
Medication reconciliation is a comparison of the patient’s current medication regimen against the admission, transfer and/or discharge orders for the purpose of identifying and fixing discrepancies (Northwest Memorial Hospital, 2011). Medication reconciliation is needed during every transition of care in order to clearly identify what medication changes are permanent, temporary and that duplicate or conflicting medications are not being prescribed. AHRQ projects that 14% of patients upon being discharged from the hospital have some sort of medication inconsistency due to a lack of medication reconciliation (Agency for Healthcare Research and Qulaity). Regardless, to date, evidenced based methods for medication reconciliation are lacking despite the need for it to occur. As a result, the Joint Commission announced in 2009 that they would no longer score medication reconciliation during on-site accreditation surveys, thereby reversing their 2005 stance (Agency for Healthcare Research and Qulaity).
The concept of safety culture came from high reliability organizations. Agencies or groups such as air traffic control systems that operate in hazardous conditions but have few adverse events were evaluated for common traits. Common features of high reliability organizations include
(Agency for Healthcare Research and Quality):
- “Preoccupation with failure—the acknowledgment of the high-risk, error-prone nature of an organization’s activities and the determination to achieve consistently safe operations.
- Commitment to resilience—the development of capacities to detect unexpected threats and contain them before they cause harm, or bounce back when they do.
- Sensitivity to operations—an attentiveness to the issues facing workers at the frontline. This feature comes into play when conducting analyses of specific events (e.g., frontline workers play a crucial role in root cause analyses by bringing up unrecognized latent threats in current operating procedures), but also in connection with organizational decision making, which is somewhat decentralized. Management units at the frontline are given some autonomy in identifying and responding to threats, rather than adopting a rigid top-down approach.
- A culture of safety, in which individuals feel comfortable drawing attention to potential hazards or actual failures without fear of censure from management.”
Even though safety can be defined and measured by survey and providers at all levels, creating sustainable cultures of safety has proven difficult (Agency for Healthcare Research and Quality, 2011). Poor perceived safety culture has been linked to increased error rates (Agency for Healthcare Research and Quality, 2011). Team training is a proven intervention to improve an organization culture regarding safety by raising situational awareness (Agency for Healthcare Research and Quality, 2011). Teamwork training also emphasizes the role of human factors such as fatigue, management styles, organizational cultures and perceptual errors such as mishearing instructions. This can be addressed using simulations or classroom/lecture style sessions.
Tomorrow, I’ll cover shovel ready interventions such as TeamSTEPPS and provide a research-based comparison of each intervention discussed this week in a handy chart for you to use.
I know there are dedicated supporters of each intervention. Let us hear what you have to say! Log in and share below.
Agency for Healthcare Research and Quality. (2011 February). Nursing Home Survey on Patient Safety Culture. Retrieved 2011 10-August from Agency for Healthcare Research and Qulaity:http://www.ahrq.org.gov/qual/patientsafetyculture/nhsurvindex.htm
Agency for Healthcare Research and Qulaity. (n.d.). PSNET, Patient Safety Primer, Medication Reconciliation. Retrieved 2011 10-August from Agency for Healthcare Research and Qulaity:http://psnet.ahrq.gov/primer.aspx?primerID=1
Agency for Healthcare Research and Quality. (n.d.). PSNet, Glossary, High Reliabiltiy Organizations. Retrieved 2011 10-August from Agency for Healthcare Research and Quality:http://psnet.ahrq.gov/popup_glossary.aspx?name=highreliabilityorganizations
National Priorities Partnership. (2011 10 August). National Quality Forum, Overuse. Retrieved 2011 10-August from National Quality Forum:http://www.qualityforum.org/Topics/Overuse.aspx
Northwest Memorial Hospital. (2011). MATCH Medicatin Reconciliation Toolkit. Retrieved 2011 14-March from Northwest Memorial Hospital: http://www.nmh.org/nm/making+the++case