Structured Safety Rounds: An Effective Forum for Discussion of Medication Safety Issues

Purpose:   Pharmacists play a key role in the safe use of medications.  In response to an identified need for sharing of and learning from medication incidents, a structured discussion forum called ‘Safety Rounds’ was initiated and evaluated.

Methods:   The pilot phase of Safety Rounds, open to all pharmacists, consisted of 8 biweekly sessions facilitated by the Professional Practice Leader.  Ground rules, with emphasis on the confidential and non-punitive nature of the forum, were established. Content of rounds included medication incidents from the pharmacists’ practice and additional examples from corporately-shared critical incidents.  Satisfaction with each of the Rounds was assessed using a written evaluation tool consisting of 4 Likert scale questions and 1 open-ended question.

Results:   Of the 27 errors discussed in the 8 sessions, 85% were brought forward by staff pharmacists.  Average attendance was 25 pharmacists / students per session (range 13 – 30).  Majority of participants agreed or strongly agreed that Safety Rounds enhanced their awareness of safety issues (98%), felt comfortable sharing their ideas and opinions (93%), and would make changes to their practice as a result of Safety Rounds (88%).  A number of practical process improvements were identified and implemented, including workflow changes, revisions to training and orientation practices and creation of a new electronic tool for structured sign-over.  Workgroups were struck to refine and implement these improvements and to formulate recommendations to improve the corporate computerized physician order entry platform.

Conclusions: The establishment of Safety Rounds was well-received by the pharmacists and have resulted in open discussion regarding medication safety issues and subsequent practice improvements.  These rounds will be continued on a monthly basis given the success of the pilot.