Project Name: Medication Safety Process Improvement Project

Project Timeframe: October 1, 2008 to June 30, 2009

Project Description and Purpose:
Develop and deploy an efficient process to ensure safe medication administration:
• Define a structured practice from time of order through administration that ensures a collaborative approach to a safe and effective Medication Management System
• Reduce medication administration related events that reach the patient whether or not they cause harm
• Increase collaboration between clinicians (physicians, nurses and pharmacists)

Project Team:
The Medication Safety Process Improvement Project is focused on improving the medication delivery system. A multidisciplinary team that includes: senior leaders and members, a physician, a performance improvement specialist, Directors of Pharmacy, Director of ICU, and members of front line staff from pharmacy and nursing

Project Goals & Objectives:
• Identify and design a process that will promote a safe and efficient Medication Management System
• Identify the improvement opportunities for this process and generate improvement theory
• Conduct a pilot study involving ICU and Pharmacy based on findings
• Recommend implementation of this Medication Management System to relevant areas

Evaluation Process:
Following Rutland Regional Medical Center's model for improvement (MEDIC), the multidisciplinary team performed a thorough evaluation of the current medication delivery system. During the course of this evaluation, it was identified that improvements are needed in order to make the medication delivery and administration system more efficient and safer. We are getting close to implementing a pilot program based on the data we have collected thus far.

Project Progress/Results:
A series of activities have taken place which include a staff and physician survey to identify perceptions related to the medication delivery system, completion of a stakeholder map, development of a communication and engagement plan, creation of flow charts illustrating the current medication delivery system, review and categorization of medication events, completed the cause and effect and inter-relationship diagram. Our next steps will be to complete the improvement theory and implement the pilot program.