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OHSU Participates in International Program to Improve Patient Safety

   Portland, Ore.

OHSU is one of only 50 health systems around the world, and the only hospital in Oregon, to join this collaborative effort for increased safety

Oregon Health & Science University is one of 50 health care systems around the world selected to participate in a new collaborative program designed to improve patient safety by redesigning medication systems. The Institute for Healthcare Improvement (IHI) of Boston is sponsoring the program, ³Quantum Leaps in Patient Safety: Focusing on Redesigning Culture and Processes of the Medication System.² The program focuses on improving outcomes for patients. More than 200 clinicians and health care administrators from around the United States have joined OHSU and teams from Canada and Sweden to work together to achieve greater patient care.

"This project will be helpful in promoting safety at several levels. During the project, specific aspects of our medication system will be improved. Even more importantly, the emphasis on safety and the collaborative approach practiced by the Institute of Healthcare Improvement and the other participants has been very effective in jump-starting the safety effort. We should be able to initiate subsequent projects more quickly and completely," said Roy Magnusson, M.D., associate hospital director of OHSU medical/clinical services and emergency department physician.

As a collaborative group, some of the goals that all the institutions will work toward include:

  • Improving the communication of medication information during a patient¹s hospital stay.
  • Improving the dispensing of medications.
  • Creating a culture of safety: one that encourages open discussion and reporting of errors.

To help achieve these goals, OHSU faculty, with the assistance of IHI and other collaborative faculty, have already redesigned three processes. The new processes are:
  • Giving individual physicians feedback on prescription writing to improve the communication process.
  • More closely monitoring the administration and ordering of insulin to improve the dispensing of this frequently used medication.
  • Initiating safety briefings that allow staff to identify safety concerns through a standardized format, so they can feel comfortable about reporting these issues.

³So far, this program has been more successful than we had anticipated. Staff have been very excited about the new processes, and therefore more actively participating in redesigning them,² said Gae Ryan, Pharm.D., director of OHSU Pharmacy Services. Ryan said OHSU is taking a lead in making medication use processes safer for its patients.

According to Carol Haraden, IHI vice president, ³The incidence of adverse drug events can be significantly reduced with known safety measures, such as standardizing and simplifying the medication processes, redesigning delivery systems, partnering with patients, and creating safety cultures that minimize blame and maximize communication. Teams involved in the ŒQuantum Leaps¹ program will learn how to apply these principles and take patient safety to a whole new level in their organization.²

The method being used to make these changes is called Rapid Cycle Change. This method involves making small changes to processes, assessing the change and, if successful, moving on to bigger changes, if not making adjustments that can achieve success. Through the collaboration, OHSU staff also has been given tools to measure their performance. Every institution¹s progress on its goals is posted monthly on a secure Internet site for all participants to view. In addition, every other week the entire group participates in a conference call to facilitate communication.

³Our ultimate goal is to expand this program to all aspects of the medication system by building on our successes,² said Ryan.

OHSU was selected to participate on this collaborative project because it had the support systems already in place to accomplish the goals of the program. For instance, OHSU has a well-established quality management process, an administrative observation team that focuses on patient safety, and a unique pharmacy and nursing team.

OHSU¹s work on the Quantum Leaps in Patient Safety collaborative began in June. Efforts will continue until next summer, when results of the program will be available.

The Institute for Healthcare Improvement is an independent, nonprofit organization based in Boston, Mass. The institute has been a leader in patient-focused health care worldwide since 1991. For more information about IHI, visit

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