Reducing adverse drug events: lessons from a breakthrough series collaborative.
Leape LL, Kabcenell A, Gandhi TK, Carver P, Nolan TW, Berwick DM. Jt Comm J Qual Improv. 2000;26:321-331.
The authors describe the experience of 40 hospitals that participated in an
Institute for Healthcare Improvement (IHI)
Breakthrough Series collaboration to reduce medication errors. Participating institutions were educated in the “Model for Improvement,” a structured set of change management practices emphasizing clear identification of goals, “rapid cycle” evaluation of intermediate steps toward the goal, and a collaborative, team-oriented approach. The successful experiences of participating institutions are reviewed, as well as cases and causes of failed initiatives. The authors review the value of this systems-based, team-oriented quality improvement effort relative to traditional “blame and train” practices focused on the individual practitioner and discuss the challenges of maintaining performance gains over time.
Using the ISMP Medication Safety Self-Assessment to improve medication use processes.
Lesar T, Mattis A, Anderson E, et al. Jt Comm J Qual Saf. 2003;29:211-226.
Patient Safety Leadership WalkRounds.
Frankel A, Graydon-Baker E, Neppl C, Simmonds T, Gustafson M, Gandhi TK. Jt Comm J Qual Improv. 2003;29:16-26.
Health for life. Keys to safer hospitals.
Berwick DM. Newsweek. December 12, 2005;46:75-78.
ISMP medication error report analysis.
Smetzer JL, Cohen MR. Hosp Pharm. 2008;43:869-872.
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