Reducing medication errors through addition of a pharmacist and standardized communication to interdisciplinary team rounding: A quality improvement project

Abstract

“To Err is Human,” a report set forth by the Institute of Medicine (IOM), significantly underestimated the magnitude of medication error impact on patient morbidity and mortality (IOM, 2001; IOM, 2015). To improve healthcare quality, IOM established five competencies to improve the quality of healthcare delivery: relationship-based care (RBC), evidence-based practice (EBP), quality improvement, interdisciplinary teams (IDT), and use of informatics. According to The Joint Commission (2015), communication errors are identified among top three root causes of sentinel events. The synchronized approach of utilizing core competencies translates into quality patient-centered care through effective communication and therapeutic relationship between patients and healthcare providers. For this Quality Improvement Project, a designated pharmacist was utilized as an active participant in interdisciplinary treatment teams where patient and staff communication occurred as an open dialogue. The pharmacist was responsible for medication orders, checking for medication interactions, medication reconciliation, and any education pertinent to medications. SBAR was utilized to improve the effectiveness of communication among team members and T-TAQ survey was offered to all nursing staff to assess their perception on teamwork and communication before and after project implementation. Medication errors were monitored by the inpatient pharmacy using an internal, dual-password protected system. Based on statistical data analysis following project implementation, medication error incidence rate decreased. Furthermore, the findings of this Quality Improvement Project support that active participation of a pharmacist during treatment team rounding improved communication among interdisciplinary participants and increased patient engagement in their care. SBAR communication maintained by the staff and organization serves as a guide for structured and effective information delivery.