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.