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Preventing Harm from High-Alert Medications

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Background: One of the 12 interventions that the Institute for Healthcare Improvement (IHI) recommends for its 5 Million Lives Campaign is "Prevent Harm from High-Alert Medications… starting with a focus on anticoagulants, sedatives, narcotics, and insulin."

Executing System-Level Changes: Three essential elements are needed to execute system-level changes in an organization: will, ideas, and execution. Will is developed by examining the status quo in an organization and agreeing that it is no longer acceptable. Ideas—changes that will make the system safer—can be found in the literature and in the experience of other hospitals and are the basis for the recommended general interventions to reduce errors and harm associated with high-alert medications. Execution, the process of making those changes real, requires commitment from senior leaders and clinical leaders, along with the organizational capacity to improve. The steps in the medication system are so interrelated that a change in one area will affect others' ability to complete their work. In addition, senior leadership and clinical leadership must visibly support the effort, connecting the reduction in high-alert medication–related harm to the overall hospital goal of harm reduction is essential.

Conclusion: The campaign's goal is to achieve a 50% reduction in harm related to high-alert medications. Employing strategies such as standardization and simplification will provide the foundation for improved medication safety.

Document Type: Research Article

Publication date: September 1, 2007

More about this publication?
  • Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

    Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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