Caring Wisely FY 2025 Project Contest

Medication Error Reduction

Submitted by Scout Hebinck on March 1, 2024 - 1:29pm Last revised by Brian Holt on March 8, 2024 - 2:55pm.
Proposal Status: 
Not Selected for This Round

Medication and fluid errors contribute the highest volume of events submitted to the incident reporting system at Benioff Children’s Hospitals, impacting length of stay, and length of mechanical ventilation and mortality. Benioff Children’s Hospitals have integrated Medication Harm Reduction into the Quality and Safety Strategic plan, which aligns with and supports the Organizational goals to achieve zero harm. A cross-bay medication errors taskforce has convened to assess medication harm data and perform gap analysis. Two major Medication Harm reduction interventions are planned: 

  • Provider prescribing education and EHR support for high-risk medication prescribing. 

  • Optimization of and compliance to use of the icuMedical smart pump library, with pharmacy and nursing associated. 

With both interventions, our aim is to reduce harm events in FY24 by 10% with projections for continued reductions beyond funding year from this foundation building initiative 

Supporting Documents: 
PDF icon mederrorreduction.caring_wisely_proposal.pdf

Comments

Brian Holt - March 2, 2024 - 9:27am

Thanks for your submission! Can you please clarify what ROI you think you will acheive by the end of FY25 taking into account the intervention will take time to fully deploy (i.e. if the proposed intervention probably won't go live until 4-6 months into FY25, estimate the ROI based on that).

Peter Oishi - March 4, 2024 - 3:58pm

Thank you for this thoughtful work! It has great potential to positively improve patient safety and outcomes!

Karen Jennings - March 4, 2024 - 4:03pm

This is a great proposal emphasizing comprehensive staff training, implementing robust double-check systems, and leveraging technology integration which fosters a safer healthcare environment. What a perfect example of interprofessional teamwork.

Allison Coleman - March 5, 2024 - 2:22pm

Would love to see this implemented at our hospital! 

April Zaat - March 5, 2024 - 2:38pm

I appreciate the quality-centered work that this group has already done to identify these two major opportunities for improvement. The inpatient champions on this team have much experience in this type of work and clearly name the role of EHR in the provider-arm of this project. Love the emphasis on processes (order sets, easy-to-find and update algorithms) over "training." As an ever-revolving cast of core residents, visiting/rotating residents and other learners, it is difficult to make sustainable change with education alone. Bravo to your incorporation of residents and interdisciplinary frontline providers on this team. I'm excited on behalf of GME in Oakland to partner with you on this.