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The new medication error learning process at USA Medical Center is SLIP: Safety Learning Improvement Process. The acronym was coined by Dr. Coby Harrison, a resident (center, white coat). Here she is pictured with USA Medical Center medical staff and administrators.
Dr. Coby Harrison has earned the $100 prize in a contest to develop a new name for medication errors, but the actual winners will be patients whose hospital staff members are ever more careful to prevent such errors.
Harrison, a third-year internal medicine resident at USA Medical Center, came up with the name — A Medication SLIP — with SLIP standing for Safety Learning Improvement Process.
While it puts a light-hearted face on the problem, it’s designed to help staff members be ever more cognizant of the problem and ever more willing to report it.
The hospital has had a committee focused solely on medication errors since 2007, but “we know there are probably more errors than are being reported,” said Dr. Rachel Weaver, a clinical pharmacist at the Medical Center and a committee member.
“When you start talking about errors, people get nervous and they don’t want to talk about it and they don’t want to get anyone in trouble,” she said.
“The word ‘error’ has a putative connotation,” she said, “so we hoped that if we changed the wording, we might do better.”
The committee challenged the entire hospital staff to come up with a word or phrase that might encourage reports, rather than discouraging them. For a week in late January, the hospital staff pondered. At the start of February. Harrison’s entry was selected as the winner.
Just thinking about the verbiage helps, said Weaver. “It gets the word out that medication errors are important and need to be reported.”
“We already had the review process in place,” she said. The issue was making sure they hear about errors, or slips, so they can examine what happened and why, and find a way to prevent it from happening a second time.
Preventing errors can be as simple as making sure that drugs that look or sound alike aren’t stored next to each other or as complex as a training program to educate staffers.
“Anytime we add new technology or new medications, we open a whole new avenue for errors to happen,” Weaver said, “so we’ll probably never solve all the problems.
“But we are getting better at recognizing where potential errors can be, looking for trends and finding a better process.”
About the University of South Alabama Medical Center
The University of South Alabama Medical Center offers patient-centered care to the central Gulf Coast with unique services including Mobile’s only Level I Trauma Center and Regional Burn Center, plus Centers of Excellence in stroke care and cardiovascular diseases, and a wide range of acute care services.
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