Bronson Methodist Hospital
Kalamazoo, MI
370 staffed beds
STEEEP
Safe - Medication errors were reduced.
Team Members
Diana Allor, RN
Nurse Manager
Pediatrics/PICU
Janine Black, RN
Risk Management
Heather Dietz, RN
Staff Nurse, NICU
Rob Germaine, RN
Staff Nurse, PICU
Kari Kloosterman, RN
Staff Nurse
Cheryl Knapp, RN
Vice President of Quality and Safety, Executive Sponsor
Peg Malnight
Outcomes Coordinator, Clinical Operations Improvement
Dave Montgomery
Decentralized Pharmacist
Eduardo Osorio
Project Coordinator, Process Management
Jennifer Pawelek
PharmD, Decentralized Pharmacist
Chris Rosey
PharmD, Pharmacy Clinical Coordinator
Chris Selles
Director of Pharmacy
Dave Short
Director of Pharmacy
Jacqueline RF Wahl, RN
Team Leader, Executive Director
Cherie Woodhams
Pharmacy Educator
Mary Woodhouse, RN
Unit Coordinator/Nurse Manager, Pediatrics/PICU
Protecting Pediatric Patients
The Problem
Bronson's patient safety committee appointed a task force to look at medication errors in pediatric patients. The team looked at all medication errors that occurred in patients 17 years and younger. There were 162 errors in the previous year with a rate of occurrence at 7.39 per 1,000 patient days. While this rate was lower than the adult population (8.67/1,000 patient days), the team decided to delve deeper and look for best practices in medication safety.
The Solution
The team selected 47 best practice methods from research on medication safety. Some of the best practices were already implemented and a part of the pharmacy routine. There were recommendations for pharmacy, nursing, physicians and educators. Some of the methods implemented included:
- Standardized pre-printed order forms including a calculation of medication dosage based on weight of the patient and visible on the order;
- Pediatric orders sent to the pharmacy are automatically flagged to alert the central pharmacist;
- One pharmacist on the evening shift assigned to process all pediatric orders; and
- Pediatric based pharmacists offering monthly education to residents and nursing staff.
The Results
Bronson saw a 44 percent reduction in medication errors for pediatric patients from August 2008 to December 2008 (4.23/1000 patient days). The previous rate from November 2006 to October 2007 was 7.39 per 1000 patient days.
