- Fostering safe medication practices
- Being consistent with accreditation and regulatory requirements
- Helping reduce hospital risk and liability due to medication errors
- Emphasizing whole system improvement
The Medication Safety Pyramid emphasizes whole system improvement by addressing the ten essential elements of the medication use process. The Pyramid is organized by using these elements which are:
Foundation Elements (Blue Zone)
- Leadership – to ensure that organization leaders understand the complexities of the medication use system, provide the support needed to improve medication use processes, and communicate appropriate goals and expectations.
- Organization – to build a strong medication safety team and ensure that medical staff, nurses, pharmacists, risk managers, and others work effectively to meet leadership’s goals and expectations.
- Culture – to minimize individual blame and discipline, provide support for those involved in errors, encourage reporting of errors and near misses, and foster communication and cooperation among staff and disciplines.
Preparation Elements (Red Zone)
- Reporting and Analysis – to identify and analyze errors and determine their root causes.
- System Assessment – to proactively identify risk points in the medication system and opportunities to improve medication use processes.
- Planning – to integrate findings from error analysis with those from system assessment and assign priorities, target dates, and responsibilities for improving processes.
Support Elements (Green Zone)
- Education / Competence – to ensure that education is ongoing and that staff demonstrate the knowledge and skills needed to ensure medication safety
- Information Management – to ensure that patient and drug information is authoritative, adequate, accurate, current, and readily available to staff
- Technology – to ensure that existing and planned technologies are appropriate for the organization, used safely, and support medication system improvement.
Redesign Element (Gold Zone – The Apex)
- System Improvement – to ensure that medication use processes are redesigned to minimize the risk of error. System Improvement is the most important of the ten elements and should be the goal of a medication safety improvement program. It focuses on redesigning and improving the following medication use processes:
- Selecting (and Procuring, Storing, Securing) medications (e.g., reducing errors due to look-alike packaging and controlling access to high-alert drugs).
- Ordering (and Transcribing) medications (e.g., minimizing transcribing; avoiding dangerous abbreviations and expressions; and improving the clarity, legibility, and accuracy of drug orders).
- Dispensing medications (e.g., minimizing compounding and calculating; using ready to administer products; and ensuring that drugs dispensed are correct, clearly and accurately labeled, and available for administration on time).
- Administering medications (e.g., ensuring that the right patient receives the right dose of the right drug by the right route at the right time. For example, organizations are encouraged to require double-checks of dosage calculations and adopt practices that ensure the safe use of infusion pumps and other drug administration devices).
- Monitoring the effects of medications on patients (e.g., for adverse drug reactions and toxic drug concentrations).
Using the Medication Safety Pyramid to improve medication safety The Pyramid supplements and enhances organizations’ medication safety initiatives. The Pyramid is fully internet based and updated to the extent practical. The website enables CareFusion to continuously provide access to already-existing web-based resources and provide additional information as it becomes available. Information found on the Pyramid emphasizes compliance with accreditation standards (especially those related to safety) and Joint Commission’s National Patient Safety Goals (NPSGs). Each organization must determine how to make the best use its information and resources. For example, hospitals may use the resources to assist in:
- Creating and building an effective medication safety improvement program
- Repairing or remodeling an ineffective program
- Maintaining or improving an already effective program
