For more than twenty years, I have been a member of our hospital's P and T Committee---an important committee whose job, among other things, is to maintain and update the formulary AND to monitor and improve the safety of medication at all times. I have chaired a subcommittee on Medication Safety for more than a decade. Each year around this time, we issue a summary of our progress in this struggle. I would like to hit the highlights of the current summary. In this past year the team reviewed quarterly medication event and adverse drug reaction reports and made many recommendations to address key safety issues. We benchmarked our own data against national data from hospitals just like us who are members of the University Healthsystem Consortium in Chicago. In other words, we put our dirty laundry out to dry and explicitly compared our progress to a national peer group--not an easy job!! We invited national experts from the ISMP, the Institute for Safe Medication Practice ,to come inside our tent and to make specific recommendations as to how we might improve our internal control processes. We tackled some specific clinical challenges in caring for patients with a wide range of diseases including diabetes, heart disease,many types of cancers, and others. In each clinical condition, we carefully tracked medication safety from quarter to quarter and year to year. We empowered multidisciplinary teams to "tell us like it really is" and we listened closely to their reports. In a word, we spent a year of tough self evaluation---asking difficult questions and sometimes getting answers that we did not like. However, we never lost sight of the real goal---to do no harm and to improve every day. The staff involved here are the unsung day to day real heroes of hospital care. What are you doing to improve the safety of medication where you work?? DAVID NASH
