Too Busy to Care

Is the Nursing Shortage Contributing to Medication Errors?

The Shortage

Staffing shortages of registered nurses have been reported in all regions of the country since 1988. Nurses who once staffed hospital beds have responded unfavorable working conditions by moving to outpatient care, managed care services, home care, and even into business roles. In less than ten years, 78 million baby boomers are going to become eligible for Medicare and greatly increase the demand for healthcare. At the same time, the remaining RN workforce will be shrinking in size as nurses retire. The average age of nurses will continue to rise, with nearly half of all practicing RNs over age 50. Already challenged to do more with less, senior nurses, working 16-20 hour shifts caring for larger loads of sicker patients, are reporting declining patient care conditions. In fact, 75% of nurses in a recent survey feel that the quality of nursing care has declined in the last two years and 42% said they would not feel comfortable having a loved one receive care in the facility in which they work.

The Effect on Patient Safety

In recent years, healthcare has come to understand that while individuals make errors that lead to injury, it is our systems that make those errors possible or fail to intercept them. Research has shown that system failures that lead to medication error, the leading cause of adverse events in inpatient care, include factors directly attributable to the nursing shortage: frequent interruptions in preparation of medications, lack of education, overworked or overtired staff, insufficient staffing and faulty organization of patient care as well as illegible orders, faulty labeling, reliance on floor stock. And yet, according to the American Nursing Association, nurses who refuse to work overtime can be threatened with losing their jobs or licenses under an alleged patient abandonment charge. Insufficient staffing can also results in unchecked pain and poor patient monitoring. In a survey of 600 hospital nurses conducted by the California Service Employees International Union, nearly one in four nurses said that patients "regularly" go without a routine medical assessment because the nurses lack the time to conduct one, despite state regulation requiring each patient to be assessed during every shift. In a national nursing survey, 56 percent of respondents believe that the time they have available for patient care has decreased.

Traditionally, nurses have served as a safety net at the bedside intercepting up to 70% of the errors that occur at earlier stages in the medication use process. Under stress, nurses report giving medications to the wrong patient, in the wrong dose, or missing a dose entirely when their attention is drawn away by a more urgent matter or in situations where their knowledge of the drug was minimal. Complicating their already demanding workloads, nurses have seen nearly 10,000 new drugs enter the market over the past 15 years. They are understandably unable to learn the pharmacology of each new drug including indications for use, drug-to-drug interactions, therapeutic ranges and appropriate lab monitoring. As a result, the number one causative factor for most serious adverse drug events is cited as "lack of drug knowledge"10 . Coupled with a decrease in patient monitoring due to time constraints, patients are put a great risk of suffering an adverse drug event.

Safeguarding Nurses and Patients

The U.S. Department of Health and Human Services projects that by 2006, 1 million nurses must join the work force to avert a nationwide shortage. But indications are that fewer than 600,000 will be ready by then.11  In the sort term, processes and systems must be implemented to ensure patient safety and retain current staff. For years healthcare has rallied behind computerized physician order entry systems and pharmacists have lobbied for more advanced information systems and distribution technologies while the needs of nursing have been largely ignored by information technology leaders. That oversight will change as hospital administrators scramble to enhance recruiting and retention efforts and nurse leaders demand the security that accessible decision support tools and information technology at the point of care can provide. By providing nurses with a technological safety net for medication administration, the hospital will not only improve patient care but also gain a critical recruitment and retention tool.

Thirty-nine percent of medication errors occur during the administration phase.12  In response to this, nursing long ago adopted the standard practice of checking the "five rights" (right patient, right medication, right dose, right time and right route) during medication administration. However, medication errors can still occur when the five rights have been verified due to basic human vulnerabilities and complex system failures that are compounded by a manic care environment. Human errors such as failing to detect the difference in a look-alike or sound-alike drug or misreading a dosage by one decimal point are common. Errors involving maximum daily dosing, allergies, and drug interactions are not prevented by merely checking the five rights. To that end, nurses benefit from a point of care administration system that goes beyond five rights to safeguard the nurse and the patient from the devastating effect of a serious adverse drug event.


Ideally, a system can ensure the five rights prior to administration by using a combination of bar-code technology and seamless interfacing to the hospital's information systems. Using standard barcode technology, the nurse scans her name badge and then the patient identification band to access the patient's profile. She then scans the medication to verify that the drug, time, route and dosage all match the order. The automated checking process intercepts errors by alerting nurses to information inconsistent with the pharmacy order. The system should further guard against medication errors by incorporating clinically relevant decision support tools beyond five rights verification. To illustrate this point, consider the following examples of actual medication errors and how an advanced point of care system could have prevented the error.

High Risk Medications - A 2-year old was administered penicillin G benzathine by a CRNA post surgery. In the recovery room, a nurse noticed that the solution in the patient's IV tubing was white and thick. An investigation found that the CRNA, in her 15th hour on the job had unknowingly administered the medication intravenously instead of via the IM route. Fortunately, the child did not suffer any serious side effects.13 

The nursing shortage is most severe in ICUs and ORs making these units particularly vulnerable to medication error.14  Organizations, such as the Institute for Safe Medication Practices (ISMP) provide safety alerts to healthcare providers regarding high risk medications. The ideal system incorporates these warnings and alerts the care provider when a high-risk medication is about to be administered. In this example, an alert would have reminded the CRNA that Penicillin G Benzathine is only to be given IM and prevented the error.

Medications with Significant Clinical Actions - A combative patient was ordered a neuromuscular blocking agent for sedation. The nurse, while struggling to control the patient without assistance, administered the medication to the man, who was not intubated or mechanically ventilated. The patient coded and suffered serious anoxic consequences.15 

The system should automatically generate alerts to clinicians when neuromuscular blocking medications, or other drug families that require significant clinical actions, are selected for administration. The warning reminds the nurse that ventilatory support is needed for the administration of these drugs.

Look Alike / Sound Alike Medications - A 60-year-old woman diagnosed with atrial fibrillation suffered a myocardial infarction following emergency surgery. The patient was ordered amiodarone, however, the assistive nurse aid on duty did not have experience with amiodarone. Instead, amrinone, which was stocked on her unit, was administered. Fortunately, the patient did not suffer permanent adverse effects.16 

In this instance, a point of care system would have alerted the nurse to the potential for confusion and informed her that amiodarone is used for arrhythmias and angina whereas amrinone is used to treat CHF. Having been made aware of the potential for an error, the nurse aid may opt to seek the advice of a senior nurse or the pharmacy.

Maximum Daily Dosing - A physician ordered, "colchicine 0.6 mg orally every 2 hours until diarrhea develops" for a patient with gout. The patient was found dead after receiving the 25th tablet, a total dose of 15 mg. The recommended dosage per course of therapy is 4 to 8 mg.17 

To provide the highest level of safety, a point of care technology should enhance maximum dosing information by incorporating a rolling 24-hour count of doses administered. In this case, a warning would have appeared as the nurse was about to administer the dose exceeding the maximum daily dosing criteria, preventing the fatal overdose.

Missed Doses - Due to an error in the medication delivery process, a patient didn't receive his prophylactic anticoagulation until 24 hours after his hip surgery had begun. He developed pulmonary emboli, which resulted in his death. The jury's decision was $539,000 against the hospital.18 

An advanced point of care medication administration system provides both a "real time" medication profile and electronic medication administration record. In the medication profile, missed or late doses are easily discernable by use of on screen highlighting, color-coding, and/or icon placement. Any medication ordered, but not given at the ordered time is easily seen.

Clinical Documentation - A 2-year-old boy underwent surgery and returned to his room with a continuous epidural infusion of hydromorphone and bupivacaine. The orders were for the nurse to assess the patient every hour. By the next morning, the patient had gone into cardio respiratory arrest and died. The nurse claimed she had done the assessment, but did not have the time to document the results. The hospital settled the claim for $1 million.19 

Nurses complain about the amount and complexity of paperwork that has resulted from a multitude of actions by regulatory bodies and the reimbursement industry. As an extension to the electronic medication record, a comprehensive administration system can capture information such as pre and post dose pain scales. The system can also allow for regularly scheduled actions such as pain assessment every shift. Utilizing this type of clinical observation capability may have safeguarded the caregiver from later disciplinary and legal action if not prevented the child's death entirely.


This nation's healthcare system is in the precarious position in which 60% of nurses today choose not to work at the bedside in our hospitals.20  Unwilling to bear hardships of nursing through this shortage˝ grueling physical and mental demands, forced overtime, increasing workloads, sicker patients, anemic pay raises, and ever more devastating liability ˝ nurses are jumping ship to seek safer harbors. Fifty percent of respondents to a survey of nurses said that "reputation of employer as a healthcare institution" or "general working conditions for nurses at the institution" was the most influential factor in deciding to accept employment.21  Recognizing this, hospitals that wish to survive this staffing crisis, will have to establish themselves at premier institutions and invest in improving bedside working conditions. According to a recent article in Modern Healthcare, "Top recruiting hospitals use technology in a way that supports performance. They invest in IS to eliminate manual tasks, enhance access to information and improve patient care - such as by using electronic medical records and patient monitoring systems."22  Few information technology solutions can be shown to provide nurses with the security that an enhanced point of care medication administration system can. This realization will soon have hospital executives declaring, "If we build it, the bedside nurse will not only come but will also stay."


1 Health Resources and Services Administration, Bureau of Health Professions, Div. of Nursing. The Registered Nurse Population, February 14, 2001

2 Buerhaus, Peter I. Second Opinion; Nursing Shortage, Washington Post. Dec. 8 2000.

3 ANA, Analysis of American Nurses Association Staffing Survey, February 6, 2001.

4 Reducing Health Care Error: Systems-Based Approaches and Nursing Perspectives. Nursing Trends & Issues; Vol. 3, No. 8 Aug. 1998.

5 Foley, Mary. Mandatory Overtime is An Alarming Trend. AANC News, Vol. 17, No. 6, June 2000.

6 San Diego Union-Tribune. Not Enough Nurses? February 21, 2001.

7 ANA, Analysis of American Nurses Association Staffing Survey, February 6, 2001.

8 Leape, Lucian, et al. System Analysis of Adverse Drug Events. JAMA, Vol. 274, No. 1. July 5, 1995

9 ISMP - A Call to Action: Eliminate Handwritten Prescriptions Within 3 Years! April, 2000.

10 Leape, L. Bates,DW, et al. Systems Analysis of Adverse Drug Events, JAMA July 5, 1995, vol 274

11 Coming crisis spurs nurse rally - 1 million recruits are needed in U.S.; 600,000 expected Boston Herald Wednesday, March 7, 2001.

12 Leape, Lucian, et al. System Analysis of Adverse Drug Events. JAMA, Vol. 274, No. 1. July 5, 1995

13 Cohen, Michael, Medication Errors. Nursing99, October, 1999.

14 Buerhaus, Peter I. Second Opinion; Nursing Shortage, Washington Post. Dec. 8 2000.

15 Neuromuscular Blocking Agents ˝ Proposed Labeling and Packaging Standards for Medication Error Prevention. USP Quality Review, February, 2000.

16 Mitka, Mike, What's in a Drug Name? Plenty! JAMA, October 22, 1999.

17 Hoffman, Richard P., Drug Death: A Danger of Hospitalization, 1989, p. 79.

19 Fiesta, Janine, Target High-Risk Areas for Medication Errors Nursing Management December, 1998.

19 Fiesta, Janine, Target High-Risk Areas for Medication Errors Nursing Management December, 1998.

20 Padron, Laura. Bedside Nurses are an Endangered Species. AACN News; Vol. 17, No. 8 Aug 2000.

21 Alspach, Factors that influence Recruitment and retention of Critical Care Nurses. Critical Care Nurse, 1992.

22 Attract and Retain RNs. Modern Healthcare, January 31, 2000.Legislation & Regulation

Legislation & Regulation

Thompson Opens HIPAA Privacy Regs for 30-day Comment Period

The Department of Health and Human Services reopened the HIPAA privacy act regulations for a new, 30-day comment period. In his statement, Secretary Thompson said, "Our goal is to achieve privacy protection that works. I believe we should be open to the concerns of all those who care strongly about health care and privacy. And after we hear those concerns, our commitment must be to put strong and effective patient privacy protections into effect as quickly as possible." Thompson also confirmed that the effective date of the Health Insurance Portability and Accountability Act privacy regulations has been extended to April 14th.

JCAHO Mandates Fifth
Vital Sign˝Pain Scale

Patients in hospitals, nursing homes and outpatient clinics nationwide will have a new vital sign monitored beginning in January ˝ their level of pain. JCAHO has issued new standards that will require physicians to treat pain until it is relieved. Under the requirement, pain levels will range from zero for no pain, to 10 for unbearable pain, as described by the patient. JCAHO's mandate will also encourage pain management through state-of-the-art technology.

If the new pain levels and the course of treatment are not monitored, providers risk losing accreditation by JCAHO.

File a Plan, or Else

Hospitals & Health Networks Volume 75, Issue 2; ISSN: 1068-8838

California is demanding that hospitals implement policies to reduce
medication errors or risk losing their licenses. A law signed last fall requires acute care and specialty hospitals, ambulatory surgery centers and urgent care facilities to implement a formal plan to eliminate or substantially reduce medicationˇ related errors by Jan. 1, 2005. Democratic state senator Jackie Speier, who introduced the bill, calls technologyˇparticularly medication ordering and administration technology-a "critical component of a total approach" to reducing medication errors.

Joint Commission Adds New Patient Safety Standards

The Board of Commissioners of the Joint Commission on Accreditation of Healthcare Organizations approved standards directly focused on patient safety in hospitals. The new standards require hospital leaders to create an environment that encourages error identification and remedial steps to reduce the likelihood of future, recurring errors. Hospitals are to implement a program for proactive assessment of high-risk activities related to patient safety and to undertake appropriate improvements. To do this, hospitals must aggregate patient safety-related data and information to identify risk to patients; apply knowledge-based information to reduce these risks; and effectively communicate among all caregivers to improve performance. Finally, the standards specify that hospitals are to place appropriate emphasis on patient rights, education of patients and their families, continuity of care, and management of human resources. The anticipated implementation date for the standards is July 2001.

Medication Errors Targeted by Washington State Legislature

Source: Seattle Post-Intelligencer

Eliminating handwritten prescriptions, sound-alike drug names and look-alike drug packaging could help reduce medication errors, according to a report released by the Washington State Health Department. The report, requested by the Legislature, describes ways to reduce drug-related errors in response to growing national concern over medical error rates.


New Report Confirms IOM Medication Error Stats

Report says medication errors are the most common type of medical errors in the United States. HCPro, a health care consulting company in Marblehead, MA, announced the results of the survey conducted to determine the nature and frequency of medical errors. HCPro surveyed about 300 risk- and quality-assurance managers, senior administrators and non-physician clinical staff members from 380 hospitals. Bob Croce, executive editor at HCPro notes that the results of the survey are almost identical to the 1999 IOM survey, with medication errors ranking at the number one in both surveys.

USP Releases First Report on Medication Errors

The U.S. Pharmacopeia, or USP, released the "Summary of 1999 Information Submitted to MedMARxSM: A National Database for Hospital Medication Error Reporting." The report summarizes the 1999 data of 6,224 medication error records from 56 facilities, including community, government, and teaching hospitals of varied characteristics. The analysis of the 6,224 reports, which include both potential and actual errors, indicated that most errors (97%) did not result in patient harm. Errors resulted in harm or death just 3% of the time. USP's data report indicates that the three most frequently reported types of errors were: omission errors, improper dose errors, and unauthorized drug errors. Also, the report states that of the five phases of the medication use process, most errors were reported to have originated in two primary areas: administering and documenting.

One in 10 Patients Suffer Harm in UK Hospitals

The Guardian

More than one patient in every 10 admitted to hospital for treatment will suffer some sort of harm while they are there, according to the first study of its kind in the UK. The study by Charles Vincent, professor of psychology, and colleagues in the clinical risk unit of University College London has never been undertaken before in the UK. They found that the rate of adverse events in their pilot study of 1,014 patients in two London hospitals was 10.8%. Since some patients suffered more than one event, the percentage of medical mishap was still higher, at 11.7%. This is considerably higher than the 3.7% recorded by a Harvard study in the US, but lower than the Australian figure of 16.6%.

Medication Errors in Pediatric Patients

Source: American Family Physician

The Institute for Safe Medication Practices (ISMP) joined with the Pediatric Pharmacy Advocacy Group to survey hospitals about medication safety practices for pediatric patients. According to the ISMP survey results, greater precautions are necessary to protect pediatric patients from potentially tragic medication errors. While many safety practices are used fairly consistently, approximately 75 percent of all survey respondents said that prescribers often or consistently failed to include the mg per kg dose on pediatric medication orders. Thirty-three percent of respondents from neonatal intensive care units (NICU) and pediatric intensive care units (PICU) reported little or no involvement by clinical pharmacists in these high-risk patient care units. While Nearly 90 percent of NICU and PICU respondents said that specialized training was required, only 66 percent of respondents from general practice units had similar training.

HIV Patients Suffering From High Rate of Prescribing Errors

Purdy BD, Raymond AM, Lesar TS. Ann Pharmacother. 2000;34(7-8):833-838

New study shows that hospitalized patients taking antiretrovirals are at risk for adverse outcomes due to prescribing errors and that this risk has increased with the rising complexity of antiretroviral drug regimens. Researchers performed a systematic evaluation of all medication prescribing errors involving antiretroviral medications in a 631-bed tertiary care teaching hospital between January 1, 1996, and October 31, 1998. A total of 108 clinically significant antiretrovirals prescribing errors were detected during the 34-month study period.

The most common errors were dosing related. Overall, errors occurred in 5.8% of admitted patients prescribed antiretroviral medications. This accounts for an increase from 2% of admissions in 1996 to 12% of admissions in 1998.

Elderly at Higher Risk of
Medical Error

Thomas EJ, Brennan TA. BMJ. 2000;320(7237):741-4

The study looked at 15,000 hospitalized patients discharged in 1992 from hospitals in Utah and Colorado, excluding psychiatric and Veterans Administration hospitals.

Non-elderly patients experienced adverse events at a rate of 2.80% compared with a 5.29% incidence among elderly patients. Preventable adverse events were more common among elderly patients, probably because of the clinical complexity of their care rather than age based discrimination.

The Observation Method

Drs. Kenneth Barker, Betsy Flynn, and colleagues presented information from a recent study on various medication error detection methods in 24 hospitals and 12 skilled nursing facilities. Direct observation of medication administration detected a 19% error rate whereas only a 1% error rate was detected by chart review, and a single error was reported (0.03% error rate) on an incident report. With direct observation a sampling of nurses are observed as they prepare and give their medications. The observer's notes are then compared with the original orders on the patients' charts to identify the percent of doses that were given (or not given) in error. Although the observation methodology will not identify prescribing errors, hospitals are able to monitor a weekly error detection rate for drug administration, which also captures drug dispensing errors. Thus, it is particularly valuable for evaluating the impact of system changes.

Promotion of a Safe Medication Environment in Long-Term
Care Facilities

Thomas P. Lombardi, BS, PharmD, FASHP, and Jeffrey D. Kennicutt, BS, PharmD

The risk of hospitalization secondary to adverse medication outcomes in elderly patients is estimated at 17%, almost 6 times greater than that for the general population. The objective of this review is to characterize drug related problems in the elderly, particularly as they apply to nursing home residents, and to describe the approach that St. Peter's Healthcare Services of Albany, New York, has taken to improve medication safety in its long-term care residents.

The study asserts that up-to-date technology must be used to maximize efficiency and effectiveness of the medication management systems. Implementation of technology that uses computer based alert systems, bar-coded medications, and handheld wireless point-of-care devices should be assessed because in the acute care arena these technologies have demonstrated the prevention of ADEs and medication related errors. However, regardless of the technology used, the electronic infrastructure must be organized to support the new technology used in medication usage. Development and implementation of these types of advances in technology will be more difficult in the nursing home setting secondary to the logistics, such as location of off-site contract services provided.

ISMP Nurses Make Bedside Recommendations

Nurses at the ISMP were asked to share their thoughts about the changes that they would make if they returned to practice. Here's what they said:

* Enlist the help of patients to safeguard against errors.

* Take the Medication Administration Record (MAR) to the bedside.

* Minimize the need for error-prone calculations.

* Ask for an independent double check of high-alert drugs before administration.

* Take time to report errors.

* Make pharmacists a valuable member of the team. As a backup, carry a palm-held device downloaded with up-to-date drug information.

* Communicate important information to the pharmacy.

* Do not sacrifice safety for timeliness.

* Review the literature for reports of errors that have occurred in other organizations.

Taking Action

Wisconsin Coalition Recommends Steps for Reducing Medication Errors

A statewide coalition of health care, consumer, and business groups in Wisconsin has endorsed a set of recommendations for improving the safety of medication use and reducing errors. The patient safety coalition made medication errors in organized health care settings its first priority, but it noted that steps are needed to reduce errors in outpatient settings like physician offices and community pharmacies as well. The coalition said its 10 recommendations "warrant immediate attention by providers, purchasers, and consumers of health care in Wisconsin."

1. Provide 24-hour pharmacy coverage either on-site or on-call.

2. Utilize available computer software to provide clinical screening to maximize patient safety in the dispensing of all prescription medications.

3. Conduct an evaluation of an integrated computerized prescriber order-entry (CPOE) system with clinical decision support for medications and other ordered services by January 1, 2002, with implementation by January 1, 2004.

4. Implement an oral and inhalant unit dose distribution system for all nonemergency medications administered within the facility by January 1, 2002.

5. Utilize a pharmacy-based and pharmacist-managed process for the preparation of intravenous admixture solutions.

6. Pharmacies and physicians should include the generic name on the label of prescription medications dispensed to patients.

7. Investigate and evaluate the use of bar-coding systems for the packaging and administration of medications by January 1, 2002.

8. Prepare and maintain written policies and procedures for the use of select high-risk medications within the facility.

9. Prescribers should institute actions to eliminate the use of symbols and phrases that are commonly misinterpreted by pharmacists and other health care providers.

10. Prescribers and pharmacists should include the intended use on all prescription orders and prescription drug labels and packages for consumers.

Philadelphia Area Hospitals Working to Avoid Medication Mistakes

Seventy-three hospitals in and around Philadelphia have launched a regional effort to improve medication safety. The hospitals in the city and Pennsylvania suburbs said they will work toward 16 safety goals designed to reduce medication errors by influencing everything from the way prescriptions are written to the types of machines used to dispense medicines intravenously. The project, spearheaded by the Delaware Valley Healthcare Council, will evaluate the systems that hospitals use to prevent errors, provide each with individualized recommendations for improvement, and give hospitals tools for educating employees and planning changes. They will be on their own when it comes to implementing any of the recommendations, though, and that could slow things down. One of the goals, for example, is to "prepare for" using a computerized system to prescribe drugs. The Delaware Valley Healthcare Council - a regional hospital group - hopes the program will become a model for other parts of the country. Participation is voluntary. Area hospitals have pledged $500,000 to support the effort. The regional council hopes to gather another $900,000 from foundations and corporations.

Massachusetts Hospitals Cite Effort on Drug Errors

The Boston Globe

Nearly every Massachusetts hospital has taken critical first steps to root out dangerous drug errors, and more than two-thirds have fully implemented a 12-step error-reduction program, according to a statewide survey. Two years ago, Massachusetts was the first state to endorse a specific set of recommendations to reduce medication mistakes, the most common form of hospital error. The move was a response to a troubling rise in the number of hospital errors. The report by the Massachusetts Hospital Association suggests that hospitals listened to that advice and are putting much of it into practice.

The Massachusetts hospitals have forged a Coalition for the Prevention of Medical Errors that includes state regulators, doctors, nurses, and others. The survey offers the first on-the-ground test of that partnership, with 61 of the state's 68 full-service hospitals answering a questionnaire mailed last spring. On average, 97 percent of hospitals in the state have at least partly implemented the 12 short-term steps the coalition recommended. Seventy percent of hospitals, on average, had fully executed the 12 steps throughout their facility. 83 percent of Massachusetts hospitals have fully computerized all pharmacy systems so they automatically issue warnings for problems like patient allergies and drug interactions. Just 2 percent have fully implemented, and 13 percent partially, systems where physicians order drugs via computer in a way that eliminates handwriting errors and provides alerts when errors are made in ordering.

Promina Healthcare Goes After Medication Errors

Promina Health System, through its eight metro Atlanta hospitals, has agreed to undertake a patient safety initiative with a group of major local employers and health insurers. The informal agreement between Promina and the Georgia Healthcare Leadership Council, a coalition of employers and insurers, pledges a cooperative effort "to make health care safer, more effective and more efficient." Promina said that it will make sure all its hospitals follow steps that some facilities now use, such as an identification system for patients with allergies to medications and food. Long-range goals include having doctors in hospitals order all medications and tests by a computer system, instead of by handwritten instructions.

VA Systems' Barcode Administration Technology

The nation's huge VA system successfully launched a system that dramatically reduces medication errors. For example, the Tucson VA reports an error rate of less than 1 percent and believes it can reduce it even more with this system. The system is called "Bar Code Medication Administration," Here's how the system works: Patients wear a bar coded identification bracelet. The nurse waves a handheld, cordless scanner over the bar coded bracelet, which, in turn, brings up the patient's records on a laptop computer on the nurse's medication cart. The nurse then scans the bar code of the medication she is about to administer. The dosage is prepackaged in the pharmacy, using the same computer and bar coding system. Once a medication is given, the computer automatically records it. If the patient has already received the drug, the computer tells the nurse that the medication already has been given. As every nurse will tell you, the nurse is responsible for giving the right drug, in the right amount, by the right route at the right time to the right patient. This system assures that this will happen. While it lacks many of the features of other computerized systems, it goes a long way in reducing errors for a very reasonable price.

Cause for Concern

NY Catches Pneumonia

Crain's New York Business

In treating pneumonia, it's axiomatic that the sooner the patient gets antibiotics, the sooner he recovers, avoiding potentially fatal complications. But at too many hospitals in New York, care for pneumonia doesn't meet medical standards. A study by the federal government of care for Medicare patients ranked the state the fourth-worst in promptly administering medication for the disease. It found that only 80% of patients receive antibiotics within eight hours.

NHS Seeks Help to End Medication Error Deaths

The Daily Express (UK)

Doctors are reacting to the deaths of two patients in a week. A teenager who was in remission from leukemia died when an anti-cancer drug was accidentally injected into his spine instead of a vein. Then an elderly man died when a local anaesthetic was injected into a vein rather than his spine. Just about every doctor have heard about these mistakes because there have been 13 such errors over the past 15 years, many of which have received widespread publicity. Last year, Government chief medical officer Professor Liam Donaldson launched his vision of the NHS - An Organization With A Memory - in which he promised action to reduce harmful medical errors. He even specified this very error, injecting intravenous drugs into the spine, as a target for "zero occurrences".

So why, less than a year on, has the very same mistake been allowed to occur? The answer, according to Donald Berwick, President and CEO of Institute for Healthcare improvement (IHI), is that doctors are human, and humans err. Berwick believes the answer lies in changing systems of work in the NHS, and cites the small number of patients who used to die under anaesthetic each year because the anaesthetist mistakenly connected the nitrous oxide tank to the oxygen line and vice versa. This can never happen now because the fittings on the tanks have been made unique and can't be mixed up. What's needed is clearly a simple failsafe mechanism to stop wrongful injection.

B.Y.O.N - Bring Your Own Nurse?!

Even in the best hospitals, patients and their families are turning to private nursing help to supplement care from staffs that are often short-handed and over-worked. As hospital nurses focus their efforts on patients in crisis, private "sitters" are there to tend to the more personal needs of patients, and provide some of the TLC services of yesteryear. Hiring a private-duty nurse or nurse's aide brings peace of mind to patients and their families, say its proponents. It can also be a hedge against substandard care, adding an extra pair of eyes and ears to prevent errors and injuries.

Sitters or certified nursing assistants do not give medications or insert IVs. A sitter will help a patient to the bathroom, and deliver a meal. If a patient is frightened, a sitter holds his hand. At night, a sitter watches that a patient doesn't fall out of bed or become wedged between the bed railings and the mattress, where the patient might suffocate.

There is general consensus among medical leaders that when you go to the hospital, you need an advocate - a family member or friend who can follow your care and watch out for errors. The private nurse or nurse's aide can serve as a stand-in who is not going to be intimidated by the place. That will be necessary until we put in more systematic approaches that build in safety.


New AHRQ Grant Perfect for Point of Care Technology

The Agency for Healthcare Research and Quality (AHRQ) announces the availability of approximately 13-14 Cooperative Agreements for up to three years to support large demonstrations in states, health care systems, and/or networks of providers to test reporting strategies and patient safety interventions. AHRQ is interested in sponsoring research that will improve the safety of patients being cared for in a wide variety of medical settings. These projects should use technology, staff training, and other methods to reduce such errors; develop replicable models that minimize the frequency and severity of medical errors; develop mechanisms that encourage reporting, prompt review, and corrective action with respect to medical errors; and develop methods to minimize any additional paperwork burden on health care professionals.

AHRQ is interested in providing resources to evaluate the effectiveness of existing systems or systems that will be functional within a few months of receipt of funds, rather than in supporting their development.

Letter of Intent Receipt Date:
April 2, 2001

Application Receipt Date:
April 27, 2001

AHRQ Clip Grant for I.T. Solutions

The Agency for Healthcare Research and Quality (AHRQ) announces the availability of Research Projects on the use of clinical informatics and information technology (IT) to reduce medical errors and improve patient safety. AHRQ seeks projects to develop and test the use of innovative technologies, such as hand-held electronic medication and specimen management systems, training simulators for medical education, computerized bar-coding, patient bracelets, smart cards, and automated medication dispensing systems in clinical settings. In responding to this RFA, applicants should address the following central research topics: (1) the role of informatics in improving clinical decision-making, reducing errors, and advancing patient safety; (2) barriers to acceptance and adoption of health information technology for improved patient safety and quality; (3) utilization of effective strategies to improve patient safety while maintaining patient confidentiality.

Letter of Intent Receipt Date: April 6, 2001

Application Receipt Date: April 23, 2001

Pursuing Perfection

The IHI has become the National Program Office for a major initiative of The Robert Wood Johnson Foundation, "Pursuing Perfection: Raising the Bar for Health Care Performance." This initiative is a $20.9 million, three-year project, whose aim is to help a small number of health care organizations achieve unprecedented performance in an array of core processes at a system level. Successful participants will provide examples of improvement not generally thought possible in the world of health care.

The Call for Proposals invites hospitals and physician groups throughout the United States to apply for selection. A National Advisory Committee (NAC) of 14 members will review all applications and select approximately 20 organizations for site visits during the spring of 2001. In July 2001, 12 of the 20 will be chosen as finalists, who will then receive small grants for approximately six months to prepare final applications. In the winter of 2001-2002, six of the 12 finalists will be chosen by the NAC as Pursuing Perfection grantees, who will receive over the subsequent 24 months awards of between $1.5 million and $3 million to help support their improvement work.

Michigan Grant Program to Reduce Errors in Hospitals

The Blue Cross Blue Shield of Michigan Foundation is seeking letters of interest from Michigan-based clinicians and researchers interested in developing ways to improve patient safety by reducing errors and accidental injuries in hospitals. The BCBSM Foundation has dedicated $500,000 to this initiative to award grants to applicants who will conduct research and disseminate information on best practices.

Michigan academic researchers, physicians, hospitals, health systems and others are invited to submit letters of interest in one of four areas:

* Determine the causes, frequency, severity and impact of medical errors on patient outcomes.

* Develop and evaluate the impact of strategies aimed at reducing medical errors on improving patient safety.

* Identify proven procedures that have successfully improved patient safety and determine how they can be spread throughout the health care industry.

* Develop approaches to disseminate information on best practices to improve patient safety.

Letters should be mailed no later than May 4, 2001.


Third Annenberg Conference On Patient Safety

St. Paul, MN, May 16-18, 2001
The third in a series of conferences to address issues vital to enhancing patient safety and reducing errors in health care. Discussion topics include:

* The nature of patient-provider communication,

* Professionals' and patients' disparate understanding of risk,

* Communications at the sharp end, Intrastaff communication,

* Effective communication as a core element in a culture of safety,

* Communicating technological needs and human factors,

* Health literacy and communication,

* Communications between providers and patients/families,

* Disclosing health care errors,

* Threat of litigation as a deterrent to disclosure and communication.

Featured Speakers:

Paul Slovic, PhD, President, Decision Science Research Institute, Eugene, OR, speaking on Emotion, Reason and Risk: Lessons for Risk Communication from Cognitive Science

Daniel Taylor, PhD, author of The Healing Power of Stories

Gordon Sprenger, President and CEO of Allina Health Systems, and

Brock Nelson, President and CEO of Children's Hospital and Clinics, Minneapolis-St. Paul, Dare To Tell It All

Bridge News

Bridge Medical & Symbol Partner to Offer MedPoint System On Handheld

Bridge Medical Inc. and Symbol Technologies Inc. announced that they are partnering to offer Symbol's rugged, pocketable and wireless handheld computers for use with Bridge's MedPoint system, which helps hospitals intercept medication errors at the point of care. The Bridge MedPoint system, first installed in hospitals in 1998, incorporates computer networking, innovative software programs and bar-code technology to help hospitals prevent medication errors and adverse drug events ˇ and improve patient outcomes in drug therapy.

Bridge Medical & PYXIS Partner to Bring Safety to the Bedside

Pyxis Corporation, a subsidiary of Cardinal Health, Inc., announced that San Diego-based Bridge Medical, Inc. has joined the PyxisPartner Program. Under the agreement, Pyxis will leverage the strength of its nationwide customer service organization and the dedicated support of its Worldwide Service Center to provide installation and service for the Bridge MedPoint medication management system. Bridge Medical offers proprietary software to help hospitals address the problem of medication errors.

Denean Rivera To Lead Bridge Medical Field Operations & Service

Bridge Medical, Inc., announced that Denean Rivera has joined the company as VP Field Operations and Service. Ms. Rivera has over 20 years experience in healthcare software and information technology. Reporting to Sr. Vice President and Chief Operating Officer, Rusty Lewis, Rivera will be responsible for customer service, including implementation and support. She will be instrumental in building the organization as Bridge continues its widespread commercial rollout of the Bridge MedPoint system and broadens its customer base.

Ms. Rivera comes to Bridge from eMD, where she served as Vice President of Product Management and Implementation. Previously with information technology vendor McKessonHBOC, Inc., Ms. Rivera developed the product management organization and standards across product families, working closely with strategic acquisition initiatives and new product rollout. Rivera began her career in the hospital clinical laboratory with a B.S. in Medical Technology from Wayne State University and later received a degree in information systems.

St Marys Hospital Medical Center Named 2001 Hits Award Finalists

Finalists were announced in the Healthcare Innovations in Technology Systems (HITS) partnership awards. The awards honor partnerships of healthcare organizations and technology vendors for the creative use of new or emerging technology to improve the quality of patient care. One winning team and one runner-up team will be announced in each of the four categories on Thursday, April 19, during the 3rd annual Healthcare Informatics & e.MD Expo & Conference.

St. Marys Hospital Medical Center, Madison, WI, and Bridge Medical, Solana Beach, Calif., have been named finalists in this awards competition for a medication tracking system that helps to reduce and eliminate medication errors at the point of care.

In all, fifty-eight teams entered the competition this year. They were judged by national healthcare information technology experts on 10 criteria: collaboration, uniqueness of the application, attainable implementation, improved patient care quality, improved management of clinical information, cost justification, attainable technology, improved quality of education and research, connectivity with other systems, and sophistication of the technology itself.