Operationalizing a Medication Safety Gap Assessment for a Large Health System

Area of Science:

• Patient Safety
• Healthcare Quality Improvement
• Medication Management

Background:

• Medication errors are a significant cause of preventable harm and mortality in the US.
• The Institute for Safe Medication Practices (ISMP) has developed best practices to mitigate medication errors since 2014.

Purpose of the Study:

• To assess the implementation status of ISMP Targeted Medication Safety Best Practices (TMSBP) in acute care facilities.
• To identify gaps in the adoption of medication safety best practices.

Main Methods:

• A 9-month assessment utilizing tools to evaluate current practices against ISMP TMSBP.
• Data collection from 121 acute care facilities on the implementation of selected best practices.

Main Results:

• 8 medication safety practices were not implemented by over 20 hospitals.
• 9 practices were fully implemented by more than 80 hospitals.
• Varied levels of adoption indicate room for improvement across facilities.

Conclusions:

• Full implementation of medication safety best practices is resource-intensive and requires strong leadership.
• Opportunities exist to enhance medication safety in US acute care facilities through continued focus on ISMP TMSBP.