Using an improvement model to reduce adverse drug events in VA facilities

Area of Science:

• Healthcare Quality Improvement
• Patient Safety
• Medication Error Reduction

Background:

• Adverse drug events (ADEs) are a significant cause of morbidity and mortality in healthcare.
• Many ADEs stem from preventable medication errors.
• A quality improvement (QI) project was implemented in the Veterans Administration (VA) system to reduce medication errors.

Purpose of the Study:

• To implement and evaluate a quality improvement (QI) project aimed at reducing medication errors within the VA system.
• To assess the sustainability of QI efforts and their impact on patient safety and cost savings.

Main Methods:

• Interdisciplinary teams participated in a 6- to 9-month project with faculty guidance.
• Teams attended three 2-day educational and planning sessions.
• Between sessions, teams implemented changes, measured results, and reported back.

Main Results:

• Over 20,000 veterans' allergy information was collected, averting 1,833 potential adverse event-causing medication errors.
• QI gains were maintained at 6-month follow-up, doubling initial results.
• Half of the teams expanded their efforts to other settings or topics, showing substantial return on investment.

Conclusions:

• Sustained gains from QI efforts are possible for at least six months with intact team structure and leadership support.
• QI facilitators should target teams struggling with new techniques.
• The QI initiative demonstrated potential for significant cost savings.