Improving Medication Safety: Put the Fire Extinguisher Down!

October 27, 2016 | Sean O'Neill

Fire extinguisher photo

In 2011, I became the first Medication Safety Officer in a large academic teaching hospital. The excitement of this opportunity was immediately accompanied by a sense of panic and the overwhelming question of: Where do I start? Having now spoken with countless clinicians in a similar capacity, this is no doubt the first or second emotion that new entrants into this role have. Although this is surely a common feeling for any professional transitioning to an enhanced role, there is not currently a great—or even adequate—playbook to follow for medical safety professionals.

What specifically about improving medication safety makes for such a daunting task? At a high level, the answer is simple: The process of ordering, preparing, and administering medication for both inpatients and outpatients has become increasingly complex and difficult to manage. From the time that a clinical decision is made to order a particular medication, through the preparation process, and finally culminating at the point of administration, there is somewhere between 5 to 7 clinicians or technicians involved. That means to safely and effectively administer a medication all of these key personnel have to properly execute their given role. And this process happens thousands of times per day in medium- to larger-size healthcare organizations. When you consider the sheer volume of medication interactions, even a small error rate can lead to unacceptable medication safety risks.

A frequently cited article by Lucian Leape, David Bates and colleagues report that the majority of medication errors occur in the prescribing phase (39%) and the administration phase (38%). Not only do the most errors occur in these two phases, but Leape, Bates et al. found that the events associate with the most harm also occur during phases—with 28% and 51% of harmful errors occurring at prescribing and administration, respectively.

In the prescribing phase alone there are countless types of errors that can occur. Below are just a few examples:

  • Ordering too high of a medication dose leading to an adverse outcome

  • The administration of two medications that adversely interact with each other, thereby reducing their efficacy or producing a toxicity

  • The omission of a medication from a patient’s home medication list that can lead to a clinical decompensation

So, with the numerous possibilities for error, where and how does a medication safety program get started? The immediate knee jerk reaction is to respond to every error report on a daily basis. This involves walking into the hospital every morning and identifying the flaws that occurred overnight and developing strategies to prevent them from reoccurring. Although this may seem like a worthwhile venture (and one that may prevent that individual event from repeating itself), are we really making true improvements to the safety of the broader medication process? Over the course of my tenure as a medication safety officer, I have found the answer to be no: I don’t believe this approach will ultimately move your organization to a safer place in the long term. On the contrary, this approach of spending hours (or even days) extinguishing isolated fires lacks the strategic vision to improve one’s systems on a macro scale. It also has a high potential to significantly reduce job satisfaction and to fatigue the care team, as it leads to a continuous and insurmountable “to do list”. (It is important to highlight that when severe harm events do occur, we must react to and address them appropriately. My contention is that this is not sustainable for each and every event).

I believe there are three major tenets that should be part of a program for systemically reducing harm from medications:

1. Look outside your walls. It may sound cliché but networking with peers and patient safety organizations matters. This is especially true in the patient safety space, which in the grand scheme is still a relatively new focus. My personality—and frankly the personalities of many organizations—is that no one else will understand how complex and how unique our systems is; therefore, we have to figure out everything on our own. Although it is true that each system may have nuisances and idiosyncrasies, the reality is that we are all working on similar challenges, and the opportunity to learn from each other is tremendous. No matter what you are working toward improving, there is very likely another clinician that has either solved it or has developed a strategy to approach it. Leveraging the mindshare of our colleagues is an essential, albeit underutilized, advantage to fostering innovative solutions.

2. Develop a process to prioritize your work. If your priorities are always changing, you do not have priorities. One of the greatest barriers to moving organizations forward is the realization that no matter what “I” do today, vulnerabilities will continue to exist in our system and patient safety events will occur tomorrow. No hospital or health system has endless resources to commit to entirely shoring up patient safety; constraints will always exist. It is paramount, however, that we both prioritize our work and set reasonable and achievable goals. For example, in my first year as medication safety officer, our team developed a plan to implement or improve seven major medication processes. How many of those projects do you think we completed fully? The answer was zero. Anyone who has worked on large multidisciplinary improvement initiatives knows that these are challenging to complete in one year. By year three in my role, we were limiting our major improvement interventions to one or two per year. This significantly increased the level of focus and success of these projects. An additional benefit was that this also allowed us to absorb and act on improvement work that surfaced throughout the year.

3. Supplement your skill gaps. A key lesson our medication safety team learned over the past 4 years is that the resources and capabilities required to develop and sustain a robust medication safety program did not all lie within the walls of our organization. Clinicians need to be equipped with the appropriate tools to succeed. For example, how do you capture and utilize the vast amount of data that is available? How do you clean transactional data in order to derive clinical insight? Many medication safety teams find themselves turning into full time data analysts, which can result in “analysis paralysis”. Worse yet, because of the universal lack of time in healthcare organizations many safety teams are not able to utilize available data and, instead, become reactive rather than proactive in addressing underlying safety concerns. Bainbridge Health was spawned from this very problem. Our team realized that the vast amount of transactional data that was available from technologies such as “smart” pumps was significantly underutilized (or not utilized at all). We were sitting on a treasure trove of data that could have been used for making proactive decisions regarding medication optimization and for implementing quality improvements; however, we had neither the time nor skillset to access and make use of that data.

Today Bainbridge Health mines and maps this data for healthcare organizations, providing them with expert analysis and offers clinical decision points for review and approval. Our goal for Bainbridge Health is to leverage our technology to obviate “data clerking” for clinicians and empower them practice at the top of the licenses ultimately offering their institutions timely, effective and rewarding improvements to their medication safety concerns.

See published article here.



Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA 1995; 274:35-43