Reducing adverse drug events: lessons from a breakthrough series collaborative.
BACKGROUND
In January 1996, 38 hospitals and health care organizations (for a total of 40 hospitals) in the United States came together in an Institute for Healthcare Improvement (IHI; Boston) Breakthrough Series collaborative to reduce adverse drug events-injuries related to the use or nonuse of medications.


METHODS
The participants were taught the Model for Improvement, a method for rapid-cycle change and evaluation, and were then coached on how to identify their own problem areas and develop changes in practice for rapid-cycle testing. These changes could be implementation of one or more known medication error prevention practices or new practices developed.


RESULTS
During a 15-month period the 40 hospitals conducted a total of 739 tests of changes. Process changes accounted for 63% of the cycles; the remainder consisted of preliminary data gathering, consensus-building, or education cycles. Eight types of changes were implemented by seven or more hospitals, with a success rate of 70%. These changes included non-punitive reporting, ensuring documentation of allergy information, standardizing medication administration times, and implementing chemotherapy protocols.


CONCLUSIONS
Success in making significant changes was associated with strong leadership, effective processes, and appropriate choice of intervention. Successful teams were able to define, clearly state, and relentlessly pursue their aims, and then chose practical interventions and moved early into changing a process. They did not spend months collecting data before beginning a change. Changes that were most successful were those that attempted to change processes, not people. Health care organizations committed to patient safety need not regard current performance limits as inevitable.
Leape
L L
LL
Harvard School of Public Health, Boston, MA 02115, USA. leape@hsph.harvard.edu
Kabcenell
A I
AI
Gandhi
T K
TK
Carver
P
P
Nolan
T W
TW
Berwick
D M
DM
D016907:Adverse Drug Reaction Reporting Systems; D019985:Benchmarking; D016303:Clinical Pharmacy Information Systems; D064420:Drug-Related Side Effects and Adverse Reactions; D005069:Evaluation Studies as Topic; D006801:Humans; D008332:Management Quality Circles; D019221:Mandatory Reporting; D008508:Medication Errors / Q000517:prevention & control*; D008510:Medication Systems, Hospital / Q000592:standards*; D017064:Process Assessment, Health Care; D012308:Risk Management / Q000379:methods* / Q000458:organization & administration; D017749:Total Quality Management / Q000458:organization & administration*; D014481:United States