Nationwide Children’s Hospital Recipient of ABMS Multi-Specialty Portfolio Program’s First QI Award
The American Board of Medical Specialties (ABMS) has awarded Nationwide Children’s Hospital (NCH) its first-ever ABMS Multi-Specialty Portfolio Program™ (Portfolio Program) Outstanding Achievement in Quality Improvement Award.
This award was established to recognize the exemplary efforts and activities of Portfolio Program Sponsors that are working to improve patient care quality, safety, outcomes, and experiences. NCH was selected because of its demonstrated leadership and innovation in planning, implementation, and the ability to spread and sustain its quality improvement (QI) efforts designed to reduce adverse drug events (ADEs).
“Receiving this award is a validation of our nine years of hard work to reduce preventable patient harm due to medication errors,” said Richard E. McClead Jr., MD, MHA, NCH’s Associate Chief Medical Officer.
In 2008, NCH set a formidable goal: to eliminate all preventable harm. At the same time, the hospital initiated a program to transform its culture of safety. A multidisciplinary adverse drug event quality improvement collaborative (ADEQC) was established in 2009. It was composed of medical, nursing, and pharmacy leaders from units with high rates of harmful ADEs. In all, approximately 30 physicians and nearly 70 additional clinicians, QI staff, and managers from multiple clinical and administrative departments participated. The ADEQC followed the Institute for Healthcare Improvement’s Model for Improvement to address medication use processes at the 450-bed academic, nonprofit, freestanding children’s hospital in Columbus, Ohio.
At the onset of the project, data showed that medication errors accounted for almost two-thirds of preventable patient harm. More than 50 percent of those ADEs were related to medication administration; a smaller percentage was related to prescribing and dispensing processes.
The ADEQC implemented several evidence-based interventions and/or successful practices aimed primarily at administration errors, followed by prescribing and dispensing ADEs. A critical care nursing QI coordinator position was established to coach, mentor, monitor, and audit critical functions related to ADE prevention.
An ADE prevention bundle and huddle process were the most effective interventions, noted Dr. McClead, who is also the lead physician of the ADEQC. The initial elements of the ADE bundle included the following: documented review of home medications, application of “the five rights” of medication administration with independent double-checks, use of smart pump libraries, accurate weight documentation, and a bar-coded medication administration when available. In 2012, additional elements including the management of appropriate intravenous tubing setups and compliance with proper administration of secondary intravenous infusions were added. Unit-based nursing “medication safety champions” conducted random monthly chart audits reviewing documentation for each ADE bundle element and reported the results to the ADEQC.
The huddle process occurred after each post-medication error. The purpose is to learn from frontline staff why the ADE occurred and how similar future ADEs could be prevented. Following a harmful ADE, an ADEQC team met with the unit’s nursing leadership and the involved medical and hospital staff members. They reviewed the ADE using a standard set of questions designed to identify opportunities for improvement. Potential interventions discussed during the huddle were entered into a Web-based platform. Those interventions found to be beneficial were presented at the monthly ADEQC meetings and, when appropriate, implemented hospital-wide.
The simultaneous initiative toward a culture of safety involved implementing high reliability, safety tools, and behaviors as well as just culture accountability, the latter of which is known as “Zero Hero.”
“The single most important factor in NCH’s success is the evolution of a culture of safety,” Dr. McClead stated. “This change led to increased reporting of medication errors by staff. As James Joyce said, ‘A man’s errors are his portals of discovery.’ By learning about ‘near miss’ events, we can make changes in the system to prevent another person from making the same error.”
To date, NCH has experienced an 85 percent decrease in harmful preventable ADEs. During this time, few ADEs caused serious harm and were not related to any deaths. This QI project has been spread to all inpatient units and many of NCH’s outpatient clinics. Additionally, this work has precipitated several spin-off QI initiatives, been shared with the 130 children’s hospitals that are members of the Solution for Patient Safety National Network, and published in peer-reviewed publications. NCH has realized a cost savings of more than $3 million.
With “Zero Hero” as the goal, NCH continues to focus on ADEs related to medication reconciliation, insulin management, vaccine delivery, and computer-generated medication alert fatigue. “In August of this year, we actually had zero harmful, but preventable ADEs. We know we can get to zero. Our persistence will eventually pay off.”
NCH’s Portfolio Program Highlights
- NCH has been a Portfolio Program Sponsor since 2011
- 160+ Portfolio Program initiatives are ongoing
- Nearly 600 instances of Maintenance of Certification credit have been issued
- Being a Portfolio Program member has helped create one standard approach for NCH’s QI work across the specialties
Pictured from left to right: David W. Price, MD, FAAFP, FACEHP, Executive Director, Portfolio Program; Andrea Renner, MBA, QIE/MOC Project Manager, NCH; Richard E. McClead Jr., MD, MHA, Associate Chief Medical Officer and Lead Physician, NCH’s Adverse Drug Event Collaborative; and Bruce Nitsche, MD, Chair, Portfolio Program Board of Directors.