Improving medication systems should result in a reduction in harm to patients. Achieving breakthrough levels of improvement in reducing harm from medications requires that an organization make changes to improve four fundamental areas in parallel:

• Culture: Develop a culture of safety where staff and leaders are committed to safety and staff are safety conscious and freely report concerns.
• High-Hazard Medications: Decrease risk of harm from those medications known to cause the most severe adverse drug events (ADEs).
• Core Medication Processes: Improve processes for ordering, dispensing, and administering medications.
• Reconciliation: Ensure that medication information is reconciled at transition points.

Many health care organizations in several countries have used the Model for Improvement* very successfully to reduce harm from medications. Using the key elements of the model, especially testing changes on a small scale with Plan-Do-Study-Act (PDSA) cycles** in all four areas, has helped organizations reduce harm from medications in their organizations by as much as 75 percent.

It is essential that medication safety efforts be lead by a multidisciplinary core team.  Forming the Team

	Setting Aims Commitment to reducing harm from medications is reflected by a strong and well-worded aim statement.
	Establishing Measures Collecting data on a key outcome measure of harm from medications, or adverse drug events (ADEs), is the only way to determine whether the safety of a medication system has improved.
	Selecting Changes Teams must test and implement changes in the four key areas — culture, high-hazard medications, core medication processes, and medication reconciliation — in order to reduce harm from medications.
	Testing Changes Testing changes to medication processes must be done carefully so as not to add additional error and harm to the system. Use PDSA cycles to test changes on a small scale before implementing them broadly.

Sources:

*Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.

**The Plan-Do-Study-Act (PDSA) cycle was originally developed by Walter A. Shewhart as the Plan-Do-Check-Act (PDCA) cycle. W. Edwards Deming modified Shewhart's cycle to PDSA, replacing "Check" with "Study."