Successful Implementation of the New Paradigm for Medication Safety: Standardization, Technology, Pharmacy, and Culture (STPC)
Vanderveen, T., & Graver, S., with Noped, J., Olympio, M. A., Petree, B., Simpson; S., Sizemore, F., & Williamson, W. (Summer 2010). The Official Journal of the Anesthesia Patient Safety Foundation.
www.apsf.org/newsletters/html/2010/summer/03_STPC.htm
Abstract
Medication errors causing harm to patients in the operating room remain a persistent problem. To develop new strategies for “predictable prompt improvement” of medication safety in this setting, the Anesthesia Patient Safety Foundation (APSF) convened a multidisciplinary consensus conference on January 26, 2010. The conference called for a “new paradigm” for future safety efforts to include 4 critical elements: Standardization, Technology, Pharmacy / Prefilled / Premixed, and Culture (STPC).
The recent intravenous (IV) infusion safety initiative at Wake Forest University Baptist Medical Center provides an excellent illustration of how implementing the new paradigm can successfully improve medication safety, clinician satisfaction, and operational efficiency from the operating room to post-operative care.
One anesthesiologist described the initiative as “the smoothest implementation of a new technology” in his entire career. Selection and implementation of a new “smart” IV infusion safety system with syringe and large-volume pumps on a common platform was the catalyst for standardizing infusion technology, drug libraries, concentrations, dosing units, and dosage limits medical-center wide.
In this case study, operating room and intensive care IV infusion therapy at Wake Forest Baptist before and after the initiative, the change process, lessons learned, and results achieved through the implementation of STPC are reviewed.