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9/25/2003

Michigan Health System Focuses on Medication Safety

Donna Young

Pharmacist John F. Mitchell, medication safety coordinator for the University of Michigan Health System (UMHS) in Ann Arbor, said he is a medication safety "hound" and takes his job of promoting safe medication practices very seriously.

"I'm constantly talking about it," he said. But, he added, it takes more than one person in a health system reverberating about medication safety awareness to have a continuing positive effect.John Mitchell

UMHS Chief of Staff Darryl Campbell, who is also the health system's patient safety officer, is adamant that all employees–from physicians to cleaning staff–attend a patient safety orientation course that is given at the start of employment, Mitchell said.

"If we are going to take patient safety seriously, we must promote a culture where all employees understand it," he said.

Recognition of champions. UMHS–a three-hospital health system with 865 licensed beds, 30 health centers, and 120 outpatient clinics–has implemented a program that recognizes "medication safety champions" for making the medication-use process safer, Mitchell said.

The special recognition, he said, is awarded once a month by the health system's medication safety committee, which Mitchell cochairs.

All of the health system's staff members are eligible to receive the award.

"It is a special award, so we don't want to give it to just everybody in the hospital," he said, "but on the other hand, if there are 10 [staff members] who are deserving of it for the month, we will give it to 10. If there is only 1, we will give it to 1. But it basically has to be someone who consistently supports our efforts to improve medication safety."

Award recipients receive a specially designed pin that has the UMHS logo on it and designates the person as a medication safety champion, Mitchell said.

"We make a big deal out of it," he said. "We go to their department meeting and try to make it as special as possible with as many people there when we present it. The people who have gotten it so far are very excited about it and very proud to wear the pin."Medication Safety Champion

A clinical pharmacist in the intensive care unit, Mitchell said, was recently awarded the pin for "constantly preaching medication safety" to the health system's medical staff and other employees.

"This pharmacist spends a good deal of his time echoing some of the things that I have told him in the past, and that's good because that is a person who is going to take my message and get it out to a lot more people," he said.

Risk management. A health system's success in promoting medication safety, Mitchell said, relies on a strong risk management department that is supportive of a nonpunitive environment.

"They have to be able to walk the walk and talk the talk," he said.

In his role as medication safety coordinator, Mitchell reviews all reports of medication errors and near misses for UMHS's three main facilities–University Hospital, C.S. Mott Children's Hospital, and Women's Hospital–and the health system's outpatient facilities.

Most of the medication-error incidents he reviews are reported by hospital staff, Mitchell said.

Staff members at UMHS's outpatient facilities report fewer errors than do hospital personnel, he added.

"I never like to say they don't have as many errors [as the hospitals] because we never know that for sure," Mitchell said. "Whereas in the hospitals, we really concentrate our efforts to make sure we report errors and near misses."

Some error reports need immediate corrective action, he said, and could be as simple as adding a warning about a certain drug product to UMHS's medication administration records system.

Other errors may require more in-depth review and development of an action plan by a multidisciplinary team.

Mitchell meets with the health system's medication safety committee two hours every month to review incident reports, medication safety literature, and to discuss errors that have occurred at other facilities and the potential for the same errors occurring at one of the UMHS facilities if action is not taken.

The committee presents a monthly written report to the health system's pharmacy and therapeutics committee, Mitchell said.

Mitchell also participates on the health system's multidisciplinary sentinel-event and adverse-event teams.

"Everything we do is systems related," he said. "We don't go after people. We have a nonpunitive process in the hospital, and we look at the systems to determine how we can shore up those systems to make them as safe as possible."

Michigan's innovation. Mitchell, who joined UMHS as part of the health system's design team for its computerized prescriber order-entry system–an ongoing project–said he is UMHS's first medication safety coordinator and owes creation of his position to the innovation of his pharmacy director, James Stevenson.

"He felt strongly that we should be a leader in medication safety and decided to create that position and was able to get funding for it."

Mitchell applauded Blue Cross Blue Shield of Michigan for encouraging health systems to employ a "specifically trained, dedicated" practitioner in at least half of a full-time-equivalent position to "enhance detection of medication errors, oversee analysis of their causes, and coordinate an effective error reduction plan" as part of its program that pays incentives to hospitals that meet certain performance standards.

"That really gets the attention of everyone in all the hospitals in Michigan to say that [medication safety coordinator] is a needed position that is recognized" by Blue Cross Blue Shield of Michigan, Mitchell said. "The very fact that it is on there now as one of the initiatives recognized by someone at that level, certainly of financial importance to the hospital, I think sends a clear message to administrators that that's an area that Blue Cross wants us to get into."