Blood Transfusion Verification and Specimen Tracking
Going Beyond Medication Safety in Search of Optimal Clinical Outcomes using Barcode-enabled Point of Care Technology
Ensuring medication safety must extend beyond verifying "the
five rights" of medication administration.
True patient safety must also include error-free blood product
administration and specimen collection.
In addition to the common sources of medication error - physician
ordering, transcription, dispensing and administration - these two factors may
introduce error into the effective and safe treatment of hospitalized
patients. First, like pharmaceuticals,
blood products are ordered by physicians to be used in the therapeutic treatment
of patients. These products must be
dispensed from the blood bank, matched to the original order and administered
to the patient without error. Secondly,
for many medications, proper therapy is dependent on laboratory specimen
analysis. For example, digoxin and
coumadin are two medications that require regular monitoring of the patient's
blood level. Specimens drawn at the
incorrect time, in an improper manner or from the wrong patient are likely to
cause the laboratory to report inaccurate results
that may affect diagnosis and treatment.
A barcode-enabled point of care system (BPOC) enhanced with blood and
specimen verification capability can provide a comprehensive safeguard while
facilitating the desired medication outcomes.
Since the 15th century the medical profession has been fascinated by the role
blood plays in the vitality of the human body.
Over the centuries, physicians tried to transfuse animal blood and even
cow's milk to restore human health. Then in 1900, the ABO blood group system
emerged. The discovery of the anticoagulant properties of sodium citrate soon
followed in 1914. With these advances,
blood banking, as we know it now became possible. Still, one significant
challenge has yet to be overcome-blood is a finite resource for which demand is
quickly approaching supply. In 1999,
Americans donated 13.6 million usable units of blood, and 12.4 million units
were transfused, says the National Blood Data Resource Ctr. This was an increase of 8 percent over the
11.5 million units transfused in 1997. Separate studies by Frost & Sullivan
and the National Blood Data Resource Ctr. confirm that demand for blood is
rising much faster than donations, a potential crisis for those in need as the
annual surplus threatens to decline. Various actions are being taken by
government agencies and the blood banking industry to mitigate these
circumstances but still more must be done by healthcare providers to ensure
that they are optimizing the use of blood products for the therapeutic good of
their patients.
Our nation's blood supply is
safer than it ever has been. According
to the American Association of Blood Banks (AABB), there has been a 10,000-fold
reduction in the risk to patients from transfusion-transmitted infectious
diseases in recent decades. However,
there has been little progress in reducing the noninfectious hazards of
transfusion, the most common of which is the administration of incompatible
blood types. Blood, like medication, is prone to administration errors during
transfusion. Most errors result from
administration of properly labeled blood to an unintended recipient. As a result, more Americans die each year
from receiving the wrong blood than contract HIV through blood transfusions. In
fact, the administration of as little as 30 mL of incompatible blood can be
fatal. Even autologous blood units,
provided by intended recipients for their own use, are subject to process
errors that may result in transfusion of a blood product to other than the
intended recipient. A study in New York
found that about 1 in 12,000 transfusions went to the wrong person. Given the
distribution of blood types, the authors calculated that 1 in 600,000
transfusions would be expected to be fatal. With 14 million transfusions in the
U.S. annually, that implies about two-dozen fatalities each year are due to
mistaken identity. These data may be
underestimated according to Dr. David Kessler, former head of the FDA, who
believes only one of every 100 fatal reactions is reported. In the U.S. alone there may be as many as
2,600 fatal transfusion episodes each year that go undetected or
unreported.
A less prevalent but still
significant problem relating to proper patient identification occurs when
pre-transfusion laboratory samples are collected. Specimen collection errors
lead to incorrect test results, patient discomfort, and in a few cases, death.
However, because specimen errors cause fewer deaths and malpractice suits than
medication errors, they are often underestimated. Documented studies show that specimen errors are a significant
threat to patient safety. In one such
study, a prospective analysis of all blood samples submitted to a laboratory
was performed. Incorrectly labeled specimens (rejected samples) were tested for
ABO and Rh type, and routine antibody screens were performed. Test results
found that specimens that failed proper collection procedures were 40 times
more likely to have a blood grouping discrepancy. Hence, strict adherence to labeling requirements results in a
significant decrease in erroneous blood typing.
While the dependency of blood
typing on accurate specimen collection is clear, the relationship between
specimen management and medication therapy monitoring is less direct but no
less critical to optimizing patient outcomes. Clinical laboratory tests, an
extension of the patient's physical assessment, can facilitate, enhance, rule
out, or confirm diagnostic or clinical management decisions. Clinicians, using
reports generated by clinical laboratories, need confidence in the reliability
of those results knowing that errors leading to adverse specimen events can
occur throughout the specimen management process. Patient preparation, specimen collection, and identification are
a few of the nonanalytic factors that can contribute to variability in the
testing process. The quality of a laboratory's work can be no better than the
quality of the specimens submitted for analysis. Any error, inside or outside the laboratory, can cause delays in getting
test results, unnecessary re-draws, costly re-tests and incorrect treatments
that increase the cost of care, decrease patient satisfaction, and may put the
patient at risk for an adverse event.
Recent shifts in hospital
personnel patterns, from centralized to decentralized phlebotomy collections,
have made the specimen collection process especially vulnerable to error
because less seasoned personnel are increasingly charged with the task. This is evident in the CAP's Q-Probes
quality improvement program that checked more than 4 million wristbands for
accuracy in 1991, 1993, and 1995. The data showed an increase in total error
rate from 2.7 percent in 1991 up to 5 percent in 1995. Consider a scenario in which a hospital has
recently switched from centralized to decentralized phlebotomy collections. Now
instead of six phlebotomists collecting samples in the hospital, over 150
nurses or caregivers are doing collections.
Henri Manasse, president of
the American Society for Health-System Pharmacists commented on the problems
associated with multiple steps done by personnel whose skills are extremely
varied saying, "Perhaps our move to building an appropriate technology
infrastructure in the U.S. hospitals will provide some additional measure of
safety so that accidents might be avoided."
Reducing human error continues to be one of the key goals of automated
systems in the hospital. Unfortunately, specimen and blood handling procedures
in most hospitals are still highly dependent on human factors. Generally
speaking, a specimen is drawn and transferred to the laboratory where it is
analyzed. The diagnostic instrument is
linked to an inventory database and identifies a unit or units of blood that
most closely match the patient's specimen.
The compatible unit is appropriately labeled and carried to the patient.
The caregiver visually compares the information on the compatibility label
generated in the laboratory to the information on the patient's wristband prior
to beginning the transfusion.
Recognizing that patients are
vulnerable in this highly manual process, researchers Whitsett and Robichaux
investigated the use of the direct observation method to identify deviations in
standard operating procedure during blood transfusion and found that it was
effective in detecting errors but "expensive and labor-intensive." They
concluded, "the development of an affordable system that would not permit
collection of samples, administration of medications, or transfusion of blood
without accurate identification of the patient via the wristband would lead to
a substantial reduction in medical events."
Indeed, such systems exist today.
A barcode-enabled point of
care system (BPOC) enhanced to verify medication administration, accurate
specimen collection and blood product compatibility can result in fewer adverse
events and improved clinical outcomes for the patient. When a patient comes into the hospital, a
band with a unique barcode identifier is placed on his wrist. When a blood sample is collected for
crossmatch, a scanner is used to capture the barcode on the patient's wrist. A
portable printer then prints out barcode labels that go on the collected
samples to be sent to the blood bank. Before a unit is given to the patient,
the barcodes on the patient's wristband and those on the unit of blood are scanned
to ensure a match. A further check is made to verify that the compatibility
label placed on the unit in the laboratory is correctly matched to the label on
the bag provided by the blood bank. If
there is not a match, the device alerts the caregiver that the blood is not to
be given.
In a similar fashion, a
barcode-enabled specimen-tracking program assures a permanent link between the
patient and the laboratory specimen to prevent identification errors on lab
samples. At the time of specimen collection, the system captures the
phlebotomist or nurse identity and verifies the patient identity before
checking that tests have been ordered for the patient and that the clinician is
using the correct specimen container.
Once the verification process is complete, the clinician uses the system
to print a barcode specimen label at the point of care that clearly states the
patient's identity, the identity of the nurse or phlebotomist who drew the
sample and the exact date and time of the draw. The label is affixed to the collection container and the specimen
is sent to the laboratory. The increased labeling accuracy results in fewer
redraws for patients and speeds processing once the specimens are received in
the lab.
Industry experts, as well as
standards organizations such as JCAHO, AABB and the CAP Laboratory
Accreditation Program, emphasize that healthcare organizations should have
unique patient identifier processes and computerized verification in place to
take human fallibility out of the equation. In a study conducted by Marconi,
Langeberg, Sirchia and Sandler, errors in 177 cases of incorrect transfusion
were analyzed. Each case involved at
least one and up to seven failures to detect incorrect identity of blood or
patient, leading to transfusion to the wrong patient. The bedside check failed
to detect discrepancy in blood or patient identity in a total of 80 of the 177
cases, despite being carried out by two people. In contrast, a trial of BPOC technology found that up to a 71
percent reduction in errors could be
realized by standardizing the current process while simultaneously implementing
a BPOC system. Human diligence simply cannot achieve the level of safety of a
BPOC system.
There are still other
advantages of BPOC verification
system. A comprehensive BPOC system
also documents every step of the transfusion and specimen collection process
providing an accurate audit trail for quality improvement purposes. Training
time is minimized, as the system visually prompts the caregiver through each
step. The need for a second nurse to
verify the transfusion administration is eliminated and phlebotomy activities
can easily be validated for billing purposes.
Since transfusion must begin within thirty minutes of the unit being
issued from the blood bank (unless refrigerated) or be discarded, delays in
administration such as the nurse having to hunt for paper-based orders may
result in the wasting of precious blood inventory. Electronic verification at
the bedside through the BPOC system eliminates this waste. In addition, patient and labeling
misidentification risks are significantly reduced thus lowering hospital
liability exposure. A single
catastrophic sentinel event, such as the 1995 transfusion error of a young auto
accident victim that occurred in New York City in which the family reached a
$2.2 million settlement with the
hospital, could do irreparable damage to the reputation of a hospital - an
event that need not occur with a sophisticated BPOC system in place.
A 1987 survey by the American
Hospital Association showed that bar codes were used most often in materials
management, not in clinical applications.
Little has changed since then according to the Institute for Safe
Medication Practices' Medication Safety Self Assessment survey conducted in 2000. While 43% of hospitals had discussed the
possibility of bar coded drug administration, only 2.5% used this technology in
some areas of the hospital, and less than 1% had fully implemented it
throughout the organization. Even
fewer have capitalized on the value of these systems to further safeguard
patients from transfusion errors and the consequences of inaccurate specimen
collection. With adoption will come a
significant decrease in the number of injuries and deaths due to human
error. Hospitals will also begin to
realize improvements in medication therapy outcomes, lower costs due to
elimination of dangerous and wasteful misadministration of expensive blood
products, increased patient satisfaction as a result of fewer re-draws and
greater caregiver confidence in the treatments they administer. A BPOC system, enhanced with blood and
specimen tracking functionality will have the intended positive outcome -
taking medication safety beyond the five rights and eliminating patient risk
while optimizing clinical outcomes.
Legislative & Regulatory
NEW MARYLAND LAW
NPSF Listserv
The Maryland Patient's Safety Act of 2001 (HB 1274) took
effect in July requiring the Maryland Health Care Commission to study the
feasibility of developing a system for reducing preventable adverse medical
events and requiring the Commission to issue a final report, on or before
January 1, 2003, to the General Assembly on the Commission's recommendations.
Read the entire piece of legislation at: http://mlis.state.md.us/2001rs/billfile/HB1274.htm
Congressional Briefing on Patient Safety
The Washington Daybook
The Healthcare Leadership Council held a members and
congressional staff briefing on new developments to reduce medical errors and
improve patient safety. Participants in
the hearings included individuals from:
Quest Diagnostics, Cardinal Health, AdvancePCS, and the Washington
Veterans Affairs Medical Center.
AHA and others laud proposed Patient Safety Improvement Act
AHA News Now
The AHA and other health care groups wrote to Sen. Edward
Kennedy, D-MA and chair of the Committee on Health, Education, Labor and
Pensions, saying that, in its draft form, Kennedy's legislation would improve
medical safety by creating a voluntary, non-punitive environment in which
caregivers may share medical error and other patient safety information without
fear of reprisal. Joining the AHA were the Association of American Medical
Colleges, Healthcare Financial Management Association, National Association of
Children's Hospitals, National Association of Public Hospitals and Health
Systems, National Association of Urban Hospitals, Premier Inc. and VHA Inc.
Research
AHRQ Says "Prove It"
The Agency for Healthcare Research and Quality (AHRQ)
released new evidence on practices that could improve patient safety throughout
the nation's health care system. The evidence report, compiled by AHRQ's
Evidence-based Practice Center at the University of California San
Francisco/Stanford University <http://www.ahrq.gov/clinic/epc/ucsfepc.htm>,
reviewed the evidence on a total of 79 patient safety practices. The report, Making Health Care Safer: A Critical Analysis of
Patient Safety Practices, is the
result of a comprehensive review of the literature from medicine, aviation, and
other relevant fields. The National Forum for Health Care Quality Measurement
and Reporting (NQF), plans to use this information to develop a list of
measures that patients throughout the nation can use to determine the actions
that hospitals and health care facilities have taken to improve safety.
Copies of the full report can
be found on AHRQ's web site at <http://www.ahrq.gov/clinic/psafety/>.
Study: Errors Less Deadly Than Thought
JAMA, July 25 - Vol 286, No. 4
A controversial study published in the Journal of the
American Medical Association suggests that medical errors are to blame for two
to three patient deaths per 10,000 hospital admissions, instead of 15 or more
deaths per 10,000 admissions, as previously estimated. The study examined 111 patient
deaths at seven Veterans' Affairs hospitals from 1995 to 1996. Its conclusions
are a direct challenge to the Institute of Medicine report, which cited
estimates based on two previous patient-mortality surveys that anywhere from
44,000 to 98,000 people die each year from medical errors in U.S. hospitals.
The study's authors said the results showed medical errors are common but also
indicated that hospitals should be careful how they classify errors and deaths
in order to identify the most pressing problems.
JCAHO Releases Updated Sentinel Event Statistics
HRC Weekly News
Patient suicide remains the most constant sentinel event
reported to the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) but now represents a smaller share of overall sentinel events.
Operative and postoperative complications remained the second-most prevalent
reported sentinel event (12.9%). Medication error ranks as the third most
common sentinel event reported at 11.9% and
transfusion error accounts for an additional 2.4% of events. Patient death remains by far the most common
outcome for patients who experience a sentinel event at 76%. The statistics are
available at <http://www.jcaho.org/sentinel/se_stats.html>.
Addressing Medication Errors in Hospitals
To help address questions about the application of technology
in reducing medication errors, The California HealthCare Foundation's Quality
Initiative teamed up with Protocare Sciences to produce "Addressing Medication
Errors in Hospitals: A Practical Tool Kit."
This kit, which includes two documents, "A Framework for Developing a
Plan" and "Ten Tools," gives hospitals a practical resource for assessing
medication errors and planning error reduction strategies. For more information or to download the
toolkit, visit the Quality Initiative web site
<http://quality.chcf.org/.>
Forum Report on Serious Medical Errors
PR Newswire
The National Quality Forum (NQF) made its draft report
"Serious Reportable Adverse Events" publicly available on its website. The report identifies 27 adverse events
that should never, or rarely, occur in health care and that are proposed as the
basis for standardizing data collection and reporting of the most egregious
medical errors. Patient death or
serious disability associated with a medication error is one such never-event
on the list. Also on the list is
patient death or serious disability associated with a hemolytic reaction due to
the administration of ABO-incompatible blood or blood products. Pending
approval, the list and NQF's recommendations could be adopted on a fast track
by the federal government or by private purchasers of health care. The report and additional information on NQF
can be found on its website: <http://www.qualityforum.org>
Taking Action
The last three months marked a critical milestone in the
success of BPOC technology and the significant reduction in harmful medication
errors. Until now, the ease of
implementing BPOC at the bedside was hindered by the volume of pharmaceutical
that still do not carry manufacturer barcodes.
This past quarter the industry united in a powerful cry to mandate
manufacturer barcoding under a single standard. The combined voices reached the FDA as well as the Department of
Health and Human Services. As a result,
uniform unit-dose barcoding is a giant step closer to being a reality.
Barcoding to combat medical errors
Traffic World, Vol. 265; Issue 27
John Santell, director of the Center on Pharmacy Practice
Management (ASHP), told delegates at the Distribution Management Conference and
Expo, Memphis, that the Federal Drug Administration is drafting regulations
that would mandate the use of barcoding to better identify medications. Until
now, hospitals did not want to invest in scanners if drugs are not barcoded,
and manufacturers did not want to barcode until they are sure the hospitals
will invest in the appropriate equipment. The impasse could now be broken by
the FDA's proposed rules and the recommendations put together by the industry
coalition.
NCC-MERP recommends uniform bar codes
AHA News Now
The National Coordinating Council for Medication Error
Reporting and Prevention has issued a set of recommendations that calls upon
the U.S. Food and Drug Administration (FDA) and the U.S. Pharmacopeia (USP) to
collaborate with pharmaceutical manufacturers and other appropriate
stakeholders to establish and implement uniform bar code standards, including
standards for unit-of-use packages. The
recommendations state that patient safety can be improved by information technology
through the use of machine-readable codes such as bar codes in a standardized
format. A scannable bar code can help
guarantee that the right drug and the right dose are being administered to the
right patient.
Read the NCC-MERP white paper,
"Promoting and Standardizing Bar Coding on Medication Packaging: Reducing
Errors and ite at http://www.nccmerp.org.
ASHP House of Delegates Supports barcoding
ASHP House of Delegates has reached a consensus on barcoding
medications and wishes to "declare that the identity of all medications should
be verifiable through machine-readable coding technology and to support the
goal that all medications be verified before they are administered to patients
in the inpatient setting".
In addition, ASHP is urging
the Food and Drug Administration to mandate that standardized machine-readable
coding be placed on all manufacturers' single-unit drug packaging to "(1)
ensure the accuracy of medication administration, (2) improve efficiencies
within the medication-use process, and (3) improve overall public health and
patient safety."
ASHP calls for drug barcoding
In a letter to Tommy G. Thompson, secretary of the Department
of Health and Human Services, ASHP stressed the immediate need for regulations requiring
standardized machine-readable code on all drug product containers, including
single-dose medication packages used in hospitals. ASHP has concluded that manufacturers will not add codes to all
medication packages in the foreseeable future without a federal mandate.
Henri R. Manasse, Jr., Ph.D.,
Sc.D., ASHP Executive Vice President and CEO said, "It's shameful that drug
manufacturers are not universally employing bar codes to help protect the
safety of patients. The benefits of bar-coding technology are well recognized."
Premier, Inc. Testifies before Senate Committee on Value of Barcoding
On July 23rd, Albert Patterson, Vice President for
Contracting PREMIER, INC. testified before the subcommittee on Senate Science,
Technology and Space during a special hearing on e-health and consumer
empowerment. Mr. Patterson supported
the adoption of an electronically readable, Universal Product Number (UPN)
prominently displayed at every level of packaging and transmitted via bar code
technology into hospital and vendor information systems. According to
Patterson, "Hospitals are eager to develop and deploy this kind of technology
to help them improve the quality of care they provide and to achieve additional
economic efficiencies."
Patterson cited a study (Systems
Analysis of Adverse Drug Events, JAMA, 1995) concludes that the simple addition
of a "unique bar code identifier" on all medications used at the bedside could
prevent nearly 60 percent of all medication errors.
ISMP Tallies up the value of barcodes
ISMP Medication Safety Alert
According to 1,435 hospitals that completed the 2000 ISMP
Medication Safety Self Assessment, few hospitals have implemented barcoding
technology in the pursuit of medication safety. While 43% of hospitals had
discussed the possibility of bar coded drug administration, only 2.5% used this
technology in some areas of the hospital, and less than 1% had fully
implemented it throughout the organization. Likewise, just 2% of hospitals used
bar coding technology to dispense most medications throughout the organization.
ISMP estimates that there are
about one million hospitalized patients in the US who receive about 16 doses of
medications daily. Assuming a very conservative 2% medication error rate, about
320,000 medication errors occur daily. Using data from Leape et al. JAMA
1995;274:35-43), over 100,000 errors occur during drug administration(38%) and
35,000 during drug dispensing (11%). Using machine-readable code may prevent
most of these errors, including some that cause death or permanent injury.
ADE Triggers
IHI Continuous Improvement Newsletter #6
According to
the IHI, the process of identifying ADEs and measuring the frequency of their
occurrence is elusive. The Idealized Design of the Medication System (IDMS)
initiative has developed a solution. The tool developed by the team, based on
work by Classen, Leape, and others, uses the concept of "Triggers." Triggers,
when noted in medical charts, alert the reviewer to the possibility that an ADE
might have occurred. The IDMS team has created the Adverse Drug Event
Measurement Tool that identifies 24 Triggers that provide "clues" to studying
patient charts for potential ADEs. For a list of the triggers go to the IHI web
site. http://www.ihi.org/idealized/idms/ci0801idmstriggers.asp
NY hospitals work to improve care quality
The Westchester County Business Journal, Volume 40, Issue 30
In Westchester, and in the broader Hudson Valley region, the
Northern Metropolitan Hospital Association took the lead in assembling a large
group of hospital medical directors, nurses and pharmacists to collectively
examine the current environment in order to ensure patient safety.
Several subcommittees were
formed, headed by medical directors from the hospitals in the region. These
groups will focus on reviewing existing voluntary reporting systems evaluating
the latest technology innovations, particularly those utilizing web-based,
wireless and handheld solutions, assessing procedures that hospitals are
currently using for dealing with high-risk drug categories, and to developing
best-practice models for each category.
BPOC In the News
It is very encouraging to see that many hospitals are
moving ahead with barcoding initiatives to ensure medication administration
safety for their patients. We applaud
these trailblazers recently in the news.
Cincinnati Battles Errors
The Cincinnati Enquirer
Many Tristate hospitals have created committees to study
medical mistakes, stepped up internal training, and have changed policies to
prevent errors from happening and record the ones that do. Some are planning to
go even further by encouraging doctors to use hand-held computers to issue
prescriptions, or to implement bar coding systems that would match medication
orders to patient wristbands.
At TriHealth, which includes
two hospitals, the group plans to launch a bar coding system later this year to
avoid medication errors. Other changes - including buying new
medication-dispensing equipment and creating a patient safety council - started
months ago.
HealthSouth's Automated Hospitals
Health Care Strategic Management; Volume 19; Issue 5
HealthSouth Corp., Birmingham, Ala., is planning to build 10
digital acute care replacement hospitals over the next 5 to 10 years that will
save a nurse up to three hours a shift and reduce nurse turnover, eliminate
paper medical records, make the hospital a place where nurses want to work and
reduce medical errors and improve patient safety. HealthSouth believes that
electronic medical records will reduce or eliminate paper work and could help
the company reduce nurse turnover. For example, when medications are given to
patients, a barcode scanner will make sure the correct medications are going to
the right patient, and a thumb print reader will identify, authorize and record
the name of the caregiver. All of that data is immediately entered into the
patient's medical records.
Utah Hospitals to Test BarCode Technology
Standard-Examiner - Ogden
Ogden Regional Medical Center will begin using barcoding and
electronic ordering as a way to improve patient safety and avoid potentially
life-threatening medication errors. The new Ogden Regional's barcode system
will provide the patient with a barcoded wristband during admitting. All of the
patient's medical history and data will then be scanned into the computer
system. Medication orders are entered
into the system where they will go to the pharmacy to be filled. The medication
will be scanned to match the correct patient so the patient receives the
medication at the right dose and at the right time.
Washington Hospital Opts for BPOC
Business Journal of Portland
The Southwest Washington Medical Center staff is learning
another new technology, a system that uses a handheld laser to read bar codes
attached to medication, patient wrist bands and hospital staff ID badges. The system checks for the five rights: right
patient, right medicine, right dose, right time and right route of
administration. Southwest Washington
Medical Center officials believe that their barcode system combined with Pyxis
dispensing cabinets will eliminate the causes of 60 percent of medication
errors. A few other hospitals in the Portland area including Providence and the
VA Medical Center use bar code technology.
SWMC plans to kick off its initial pilot project this fall, with full
implementation at the hospital within a year.
Cause For Concern
Frontline workers misunderstand value of error reporting
A significant number of frontline health care workers believe
that a non-punitive error reporting culture might increase carelessness as
individuals learn they will not be punished for their mistakes, according to an
informal survey by the Institute for Safe Medication Practices. However, ISMP
said there is no evidence to support the premise that non-punitive reporting
will increase carelessness, and that frontline caregivers need to be educated
more about the value of such reporting. ISMP noted one surprising finding of
the poll is that frontline workers have a more punitive attitude toward error
reporting than managers.
Pharmacists' Ranks lag behind Demand
New York Times
As demand for prescription drugs rises, pharmacies in the
United States face a shortage of trained professionals, increasing the risk of
improper medication, pharmacists and healthcare experts say. About 6,500, or 6
percent, of the pharmacist jobs at chain pharmacies are unfilled. In hospitals,
about 21 percent, or 12,600, of the pharmacist jobs are unfilled, according to
a survey in June by the American Hospital Association. It is difficult to determine how many of
errors are caused by pharmacists but it is known that the shortage of
pharmacists hinders their ability to catch errors made by others. "The
pharmacist often represents the last safety net," said Mary Anne Koda-Kimble,
dean of the School of Pharmacy at the University of California in San
Francisco.
Case underscores the importance of specimen accuracy
Philadelphia Inquirer
A miscalculation of laboratory blood tests led to overdoses
of the powerful blood-thinning drug Coumadin and may have been responsible for
the deaths of two patients at 172-bed St. Agnes Medical Center in Philadelphia.
An incorrect number was used in an equation to determine the lab-test results
of 932 elderly patients between June 4 and July 25. The results, which
indicated patients' blood was clotting, led to higher doses of the drug being
given.
Grants
AHA to administer medication safety grant
The American Hospital Association's educational arm, the
Health Research and Educational Trust, will administer a new grant to study
improving medication safety. The Commonwealth Fund, a New York-based foundation
that supports health research, is sponsoring the $259,000 grant. The AHA's
involvement in the grant follows its recent announcement that it will award
hospitals that make significant strides in patient safety. "There is a need for
instructional materials and tools to improve patient safety," said HRET
President Mary Pittman. "This grant will go a long way to enhancing those
systems."
ASHP Launches Research Grants
ASHP PushNews
The ASHP Research and Education Foundation is offering two
research grant programs for pharmacy practitioners and one program for pharmacy
practice residents. Pharmacy practitioners may apply for a grant to support
research in medication safety or research in basic science or applied
therapeutics; applications are due by Oct. 5. The third program is for pharmacy
practice residents who plan to conduct their residency project in an area of
medication safety; applications are due by Oct. 12. For more information go to
ASHP Research and Education Foundation's Web site.
http://www.ashpfoundation.org/grants.htm
Events
P4PS Partnership Symposium 2001- Stories of Success,
October 10-12, Dallas, TX
CSHP Pre-Symposium Features State Senator Jackie Speier
October 25 in Santa Clara, CA
IHI's Breakthrough Series College
October 28-30 in Boston
ASHRM Annual Conference
October 29-November 1, Boston
Windows on Healthcare 2001
MS-HUG Conference
Oct. 29-Nov. 1, San Diego
IHI Calls to Actions
6 consecutive Tuesdays beginning
October 30
JCR National Conference
November 7-9, Chicago
Emerging Technologies in Healthcare
November 16, New York City
2001 ASHP Midyear Clinical Meeting
December 2-6 in New Orleans
The Global Summit on Handheld Productivity Solutions
December 4-6 in Las Vegas
National Forum on Quality Improvement in Healthcare
December 9-12, New York
Bridge News
BRIDGE MEDICAL HELPS HOSPITALS MEET JCAHO'S NEW INDUSTRY SAFETY STANDARDS
Bridge Medical, Inc., announced that the Bridge MedPoint
system can help hospitals meet the new industry safety standards enacted by the
Joint Commission on Accreditation of Healthcare Organization (JCAHO), as well
as reduce medication errors. MedPoint is an easy-to-use, integrated and
comprehensive system designed to address a broad spectrum of patient-safety
concerns.
Effective July 1, 2001, JCAHO
enacted new mandatory patient-safety standards for the nearly 5000 U.S.
hospitals that JCAHO accredits. These new standards require hospitals to place
an emphasis on effective information management. All hospitals must aggregate
patient safety-related data and identify risks to patients.
According to the 1999
Institute of Medicine Report, medical errors kill as many as 98,000 Americans
each year. Studies indicate that seven percent or more of these deaths are
caused by medication errors. "The sad and simple truth is that many of these
deaths are preventable with affordable health information technology," said
John Grotting, Bridge CEO. "Bridge was founded to help healthcare providers
eliminate medication errors, prevent adverse drug events and improve the
outcome of medication therapies."
The MedPoint system provides a
safety net at the point of care by checking the "five rights" (right patient,
right drug, right dose, right route of administration, right time), by alerting
nurses to high-risk medications (look-alike, sound-alike, maximum daily doses,
etc.), and by verifying laboratory specimen and blood transfusion identification.
Before a medication or blood component is administered or a lab specimen is
drawn, the nurse scans his or her ID, the patient's ID and the medication or
blood product.
New Jersey Hospital Association and Bridge Medical Join Forces
The New Jersey Hospital Association announced a three-year
partnership agreement with Bridge Medical to promote the company's MedPoint(TM)
medication management system to help New Jersey hospitals reduce medication and
transfusion errors. "Bridge's
state-of-the-art technology will fortify the efforts of our hospital members as
they continue to work diligently to improve their care processes to reduce
medication errors," said NJHA President and CEO Gary Carter. "We remain
dedicated to providing our members with innovative solutions designed to help
improve quality and enhance patient safety."
"The use of barcode readers to
quickly and accurately verify patient identification, and drug or blood product
characteristics," noted Grotting, "has proven lifesaving for both medications
and blood products. Studies show that BPOC systems like Bridge's have resulted
in up to a 74 percent documented decrease in medication errors."
Headquartered in Princeton,
N.J., the New Jersey Hospital Association (www.njha.com) is a leader in advocacy,
education and information. As the premier statewide healthcare association, it
partners with its 107 members so they can better provide accessible, affordable
and quality healthcare. Dedicated to quality improvement, NJHA has collaborated
with federal and state government, physician groups, consultants and others to
address healthcare quality concerns. Additional efforts in the quality arena
include continuing education, ongoing efforts in data collection and
benchmarking, and the formation of a Quality Institute to continue developing
member resources in quality improvement.
Bridge to Present at P4PS Conference in October
Bridge customer, Weirton Medical Center will be presenting
"Responding to America's Other Drug Problem:
A Technological Solution to Report, Reduce, and Prevent Medication
Errors at the Point-of-Care".
With the integration of the
Sagent Solution into our product offerings, Bridge can easily aggregate data to
provide hospitals with a unique perspective of the data-data that combines clinical
and financial information to support the hospital in optimizing therapeutic
outcomes and operational efficiencies. Examples of the benefits that can be
derived with the combined Bridge-Sagent solution include assisting physicians,
nurses and pharmacists in complying with ORYX indicators, tracking adherence to
guidelines and protocols, and comparing data between hospitals.
VA's National Center for Patient Safety Incorporates 'Beyond Blame' Video in Employee Training
The Department of Veterans Affairs (VA) announced that it
will feature Bridge Medical's "Beyond Blame" video in its recently revamped
training program for new hospital employees.
The ten-minute, award-winning documentary deals with an issue generating
heat among health care providers, payors, purchasers, consumers and regulators:
medical errors. "The video will be shown to thousands of new hires at 163 VA
hospitals serving close to four million patients nationwide," said VA National
Center for Patient Safety (NCPS) Director James Bagian, MD, PE.
"'Beyond Blame' is gripping,"
noted Bagian. "It will help our trainers demonstrate the importance of patient
safety to both patients and clinicians. Showing it at the beginning of each
new-hire training session creates 'a teachable moment' that dramatizes the
issue of patient safety." The video will be incorporated in VA's 45-minute
patient safety training video.
"'Beyond Blame' features three
gripping case histories," explained Bagian. "It tells the stories of a
pharmacist, a nurse and a physician who have each been involved in a fatal
medication administration error. It shows in dramatic fashion why patient
safety is the job of everyone in the hospital. We are using the video to help
new employees understand, in a visceral way, their role in preventing
potentially deadly medication errors."
'Beyond Blame' premiered at a
1997 American Society of Health-System Pharmacists meeting, and won the
Institute for Safe Medication Practices' "Cheers Award" in 1998. Since then,
more than 12,000 copies have been distributed to health care professionals and
others interested in preventing medication errors.
"We produced this video to
tell the industry how important it is to focus on improving processes, rather
than blaming health care professionals," noted Grotting. "Physicians, nurses,
and other hospital employees are under tremendous pressure. And after all, as
the Institute of Medicine said in its now famous 1999 report: 'To Err is
Human.'
Microsoft Selects Bridge MedPointtm System as MS-HUG Award Finalist
Barcode technology developed by Bridge Medical, Inc., to
prevent medication and other medical errors has been selected as a finalist for
the 2001 Microsoft Industry Solution Awards for Healthcare. One of three
finalists in the "Acute Care-Clinical/Patient Information Systems" category (21
finalists were chosen in seven categories), Bridge was selected for its
MedPoint system, which uses "barcode technology to track and prevent medication
errors at the point of care." The MS-HUG awards recognize independent healthcare
industry software vendors that best utilize Microsoft technology. Finalists
were chosen based on their use of the latest Microsoft technology to provide
tangible business benefits to healthcare organizations . . . MedPoint, for
instance, helps hospitals reduce medical errors, thereby saving lives and
money. The seventh annual Windows on Healthcare 2001 MS-HUG Conference will be
held Oct. 29 to Nov. 1 at the San Diego Convention Center. Winners will be
announced at a 5 pm ceremony on Oct. 30.