Two Effective Initiatives for C-Suite Leaders to Improve Medication Safety and the Reliability of Outcomes
To start, the organization initiated a collaborative effort to identify the gaps in the current implementation of the Best Practices and any real or perceived barriers to their implementation through self-reported survey data, leadership rounds, manager-led safety huddles, corporate-wide information gathering calls, and leadership observations. After that, while the leaders insisted on implementation of the Best Practices, they simultaneously allocated significant resources to build an infrastructure to help ensure their success. They built a corporate-wide system of support by initiating and leading monthly mentoring calls; they built an intranet platform to share success stories and the tools and systems that helped move implementation of the Best Practices forward; they reserved adequate time for the leaders in all 141 hospitals to participate in collaborative learning experiences; they established interdisciplinary teams to identify and address any barriers to implementation; they were actively engaged in the improvement efforts firsthand, providing leadership for infrastructure management, results reporting, and overcoming any barriers to implementation of the Best Practices.
The leaders also required frequent, focused reviews of progress and a disciplined format for measuring and reporting results, even engaging an independent consulting team to evaluate compliance with the Best Practices in a sampling of more than 65% of the hospitals in the system. And while the senior leaders clearly minimized the risk of failure, they imposed no observable consequences for failures, instead attempting to understand the failures and working to address them in hospitals with varying capabilities and resources. As a whole, the organization demonstrated a statistically significant increase (26.44%, p < 0.0011) in implementing all the 2014–2015 Best Practices. Well more than 85% of all hospitals in the system were compliant with most of the Best Practices, and the health system as a whole was impressively above national compliance levels for implementation of all of the Best Practices.
The vast improvement in adopting the Best Practices in this large organization was attainable largely because of the strong commitment and ongoing support that senior leaders provided for this strategic initiative, which we hope will provide a road map to the leaders in other organizations who want to achieve similar success.
Strategic initiative 2: Creating a learning organization
Learning is the precursor to change. From the perspective of senior leaders, it’s the difference between trying to make the workforce perform flawlessly and understanding the constraints that are keeping them from flawless work (Senge, Kleiner, Roberts, Ross, & Smith, 1994). To learn, organizational leaders must have reliable safety information systems in place to collect, analyze, and communicate information about risks and errors; workers must be prepared to report risks, errors (including close calls), and any barriers to safe work; and the leaders must possess the willingness and competence to draw responsible conclusions from the safety information and facilitate substantial changes when necessary (Reason, 1997). A learning culture is probably the easiest to engineer and the hardest to make work in healthcare (Reason, 1997). Two significant reasons for this difficulty lie with the challenges associated with learning from the mistakes of others, and our resourcefulness in fixing problems in the moment but then forgetting to report them so long-term solutions can be explored and implemented.
There are two tangible and constructive ways that leaders can take an active role in overcoming these barriers to learning and promoting a learning organization. The first way is to develop an infrastructure for required review of published risks and external errors so the organization can learn from the experiences of others. The second way is to establish a forum for welcomed visibility of leaders in patient care units so they can learn firsthand from frontline staff about the barriers to safe care.
Learning from external errors and using the ISMP Quarterly Action Agenda
One of the most important ways to prevent medication errors is to learn about problems that have occurred in other organizations and to use that information to prevent similar problems at your practice site. Experience has shown that a medication error reported in one organization is also likely to occur in another, given enough time. Because there’s a natural human tendency to “normalize” errors that happen elsewhere and believe they will never happen to you (ISMP, 2017), leaders must convey that these external errors offer valuable and necessary learning opportunities and must be sought out and reviewed regularly. They must convey that the organization is vulnerable to errors, and that they consider external errors to be a “clear and present danger” in their organization for which steps must be taken to prevent a similar occurrence.
To establish an infrastructure for learning from external errors, leaders should identify reliable sources of information, establish a systematic way to review this information, assess the organization’s vulnerability to similar events, and determine a workable action plan to address any vulnerabilities.