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Related Experiment Videos

Reducing adverse drug events: lessons from a breakthrough series collaborative.

L L Leape1, A I Kabcenell, T K Gandhi

  • 1Harvard School of Public Health, Boston, MA 02115, USA. leape@hsph.harvard.edu

The Joint Commission Journal on Quality Improvement
|June 7, 2000
PubMed
Summary

Hospitals improved patient safety by reducing adverse drug events through rapid-cycle testing of process changes. Successful interventions focused on system improvements, not individual performance, demonstrating that significant change is achievable.

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Area of Science:

  • Healthcare Improvement
  • Patient Safety
  • Medication Error Reduction

Background:

  • 40 US hospitals participated in an Institute for Healthcare Improvement (IHI) Breakthrough Series collaborative starting in January 1996.
  • The collaborative aimed to reduce adverse drug events, which are injuries related to medication use or nonuse.

Purpose of the Study:

  • To implement and evaluate rapid-cycle changes in hospital practices to reduce adverse drug events.
  • To identify effective strategies for improving patient safety through medication error prevention.

Main Methods:

  • Hospitals were trained in the Model for Improvement, a method for rapid-cycle change and evaluation.
  • Teams identified problem areas and developed/tested changes in practice, including known and novel medication error prevention strategies.

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Main Results:

  • Over 15 months, 40 hospitals conducted 739 tests of change, with 63% being process changes.
  • Eight types of changes, implemented by at least seven hospitals, had a 70% success rate.
  • Successful interventions included non-punitive reporting, allergy documentation, standardized administration times, and chemotherapy protocols.

Conclusions:

  • Significant improvements were linked to strong leadership, effective processes, and practical interventions.
  • Successful teams focused on changing processes rather than people, and avoided prolonged data collection before implementing changes.
  • Healthcare organizations can achieve substantial improvements in patient safety by adopting a proactive approach to process change.