Background and Approach

Abstract

Introduction Through the concerted efforts of its Pharmacy Quality , Risk Management, and National Environmental, Health and Safety/Patient Safety Departments, the Kai-ser Permanente (KP) Mid-Atlantic States Region developed and piloted a program for assessing safety of outpatient medications delivery systems. The program is unique to KP in that it addresses, on a national scale, issues of medication safety in the outpatient setting. To identify issues relating to medication use, the program uses a systematic approach and an implementation process that educates and trains staff, leverages known and observed practices across KP's outpatient medical centers, and provides a mechanism for periodically measuring improvement of processes and systems. The assessment program was designed to achieve the following main goals: • identify existing processes and systems susceptible to medication errors in the outpatient medical centers; • increase the use of successful practices in KP's outpatient setting by compiling known and observed successful practices and then leverag-ing that information across the program; • involve outpatient medical centers in the process both for their education and to involve them more fully (create a " sense of ownership ") in patient and medication safety; and • through development of self-assessment tools, enable KP Regions to periodically monitor processes and systems that will result in safer medication use practices.