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THE POINT OF CARE

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A Quarterly Progress Report on America's Other Drug Problem™, Volume I, January 2002

 

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CONTENTS

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SPECIAL ANNOUNCEMENT — PATIENT SAFETY SEMINARS

FEATURE ARTICLE — A RECIPE FOR SUCCESS

LEGISLATION & REGULATION

RESEARCH

TAKING ACTION

BPOC IN THE NEWS

CAUSE FOR CONCERN

GRANTS

EVENTS

BRIDGE NEWS

 

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BRIDGE MEDICAL OFFERS FREE SEMINARS TO IMPROVE PATIENT SAFETY

 

If you are a hospital administrator, nursing director, pharmacist, risk manager, or in any other role focused on improving patient safety, you will want to attend this seminar. This seminar is designed to inform hospital professionals about advances in patient safety.  This winter educational seminar series sponsored by Bridge Medical entitled "Improving Patient Safety in the Inpatient Setting" is offered free of charge as a service to the patient safety community.

 

Speakers:

JUDY SMETZER, RN, BSN — Vice president of Institute for Safe Medication Practices. Ms. Smetzer will share her expert insight on a "System-based Approach to Error Reduction."

 

MARY MICHAEL BROWN, RN, MS - Bridge Medical Senior Clinical Consultant, is a former critical care nurse manager. Ms. Brown will discuss "Automated Medication Error Reporting," and present research showing the impact of barcode technology on tracking and reducing medication errors.

 

LESLIE BROWN, RN, BS. - Senior Product Consultant for Bridge Medical. Ms. Brown has over 25 years in the healthcare setting including operating room and critical care nursing.

 

Dates and Locations:

 

+  ROSEMONT, IL - FEB 14, 2002, Sheraton Gateway Suites

+  FT LAUDERDALE, FL - FEB 15, 2002, Ft. Lauderdale Marriott

+  SEATTLE, WA — FEBRUARY 26, 2002, Marriott Sea-Tac Airport


 

To reserve your spot please call, email, or fax Amy Iacone at: 888-578-0100 ext. 5609. Fax 858-350-0115

e-mail: aiacone@bridgemedical.com

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FEATURE ARTICLE

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by Jamie Kelly

 

A RECIPE FOR SUCCESS

Gordon Sprenger shares his views on the ingredients for patient safety.

Healthcare is a complex entity.  It is a science, a business, a requisite of life, and, for some, a personal vocation.  Providing care to 281 million Americans is a challenge wrought with difficulty.  With basic access issues posing such a problem, going further to ensure that healthcare is of the highest quality and adheres to state-of-the-art medical knowledge can seem impossible.  Yet in the 2 years since the Institute of Medicine (IOM) report exposed the shocking incidence of medical error in American hospitals, individuals at all levels of the healthcare infrastructure have undergone crash courses in achieving the impossible. They have come to understand that errors are a by-product of flawed systems rather than individual negligence or incompetence.  This understanding has opened the door to an unprecedented era of quality improvement within hospitals.  Through staff training, standardization of care, diligent incident reporting, and the adoption of innovative technology, hospitals are achieving impressive levels of error reduction.  In each instance of success, one key ingredient can be found.  The hospital, and its leadership, embraced a culture of safety first.  Before the checklists were drafted and the procedure manuals reviewed, hospital executives wrangled with and committed to elemental cultural change hinged on a workplace free of individual blame.  Gordon Sprenger is one such leader who has created an environment ideal for patient safety and he is willing to share the recipe.

In October, The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Committee for Quality Assurance (NCQA) awarded one of their "Individual Leadership in Patient Safety Awards" to Gordon M. Sprenger, Chief Executive Officer of Allina Health Systems, in recognition for a career dedicated to creating and sustaining cultures of patient safety.  Earlier this year, Sprenger was also awarded the American Hospital AssociationÝs highest honor, the "Distinguished Service Award." Both awards speak to SprengerÝs 40 years of personal commitment to care models that effect real change. He has led management teams devoted to creating patient-focused health care organizations including Abbott Northwestern Hospital, Sister Kenny Institute, Minneapolis Heart Institute, Virginia Piper Cancer Institute, and, since 1993, Allina Health System. He credits his participation in the Harvard Executive Session on Medical Error and Patient Safety for starting him on a patient safety journey and moving him to proactively address medical error in his own community. As AllinaÝs quality champion, he has reached out to staff members who have been involved in adverse events and actively supports the resource intensive process of root cause analysis to address these events. He believes that patient safety must be a top priority for everyone at Allina- from board members to front line caregivers. In demonstration of his resolve, Allina has designed leadership training to foster a beyond blame culture and the health system delivers its message to "sharp end" caregivers by distributing a newsletter to share patient safety concerns and successes.

Gordon Sprenger has also led nationwide efforts to help hospitals create a culture of safety as chairman of the board of the American Hospital Association.  In recognition of his leadership, the medical technology community has actively sought his guidance.  Gordon currently sits on the board of directors of Bridge Medical, Inc. as well as Medtronic, Inc., and St. Paul Companies, Inc.  As a member of the Bridge Medical board, he has offered invaluable insight into the front-line experiences of hospital staff involved in medication errors.  He also provides a balanced perspective predicated on an in-depth understanding of the challenges facing hospitals today. His guidance has contributed to the success of the MedPoint Patient Safety system, a state-of-the-art barcode-enabled Point of Care (BPOC) system that verifies the five rights of medication administration and offers rich decision support and clinically appropriate alerts to guide the caregiver through safe administrations of medications, collection of laboratory specimens and the transfusion of blood products.  I recently had the opportunity to speak with Gordon about his own recipe for patient safety through the delivery of high quality healthcare.

 

Q: As the chief executive of a major healthcare system, what concerns kept you up at night?

A: "Oh gosh!" began Gordon, "At times, I struggled with the gap between the resources available and the opportunities that can advance medical science and improve healthcare for the public.  I've had concerns about the real problems brought on by the lack of healthcare access for the 44 million uninsured Americans.  In addition, some management issues have been an ongoing challenge.  For example, how do we develop appropriate partnerships with physicians to improve healthcare." 

Still, Gordon was quick to clarify, "Generally speaking, I didn't lay awake at night worrying.  Rather, I was energized by the challenges of my work.  I was more apt to wake up during the night excited about all the possibilities for improvement such as new clinical programs, new talent, and new services."

 

Q: In your 40 years as a hospital administrator you must have experienced medication errors that lead to serious patient harm.  How did this affect you personally and what do you believe is the appropriate role for a chief executive to assume during these times of crisis? 

A: "These unfortunate situations are devastating to everyone involved - the patient, individual caregivers, and the entire organization.  I was initially attracted to healthcare by the opportunity to provide a safe environment for patients.  As tragic as each incident is, I try to recognize the opportunity it presents to identify the root cause of our error so that it can be addressed and eliminated."

As for the role of the chief executive, Gordon pointed to his own experience with patient safety conferences.  "Most CEOs send their quality people to these conferences.  These folks will comment about how great the conference was and say, 'I wish my CEO had been here.'  I believe that the chief executive needs to attend such conferences and become the organization's champion."  Without senior leadership, Gordon sees solving the problem as an uphill battle.  "Employees look at executive focus for guidance," he said. 

 

Q: Were you and your colleagues aware of the extent of patient safety risks that have come to light since the IOM report of 1999?  Do you think administrators are more aware today than 5 years ago?

A: "For years our focus was on blaming someone for practice errors and the usual outcome was to fire that person.   A certain level of error was considered acceptable as long as the hospital was within the percentage of error deemed acceptable by medical literature," said Gordon. "I and my colleagues always had an awareness of patient safety risks on an individual basis because we dealt with the families and providers involved in incidents of medical error. To the extent that there was the possibility of a malpractice case and/or a public relations situation, there would also be Board awareness.  But, little time was spent on root cause analysis.  Each incident was treated individually without regard for the bigger picture." 

He went on to say that in the last 5 or 6 years awareness has increased and the industry has realized that, while an isolated incident can be tragic, it is the aggregate data that speaks to the magnitude of the problem.  "No question," continued Gordon, "administrators are more aware as a result of the IOM report and the publicity that generated.  As the public has lost trust in healthcare, administrators are focusing on regaining that trust and reassuring the public that they can have a safe experience in the hospital."

 

Q: Spending on information technology in hospitals is growing each year.  This includes dozens of technologies, clinical and administrative.  How do you see patient-safety related technologies prioritized on the hospitals IT plans?

A:  "Hospitals are independently deciding to invest in safety related technologies.  However, the Leapfrog Group and various health plans are putting emphasis on quality indicators as criteria for purchasing healthcare services and this certainly influences technology spending as well."

Gordon sees purchasing decisions being based on the evaluation of how administrators can support clinicians with appropriate tools to achieve best practices.  "In the past, quality and safety have always been top concerns but addressed separately.  We are now seeing quality and safety being considered as synonymous.  Some hospital boards are establishing Quality and Safety Committees in order to emphasize the importance of the two being considered as one. This means that safety related technology is now considered integral to overall clinical quality and a necessity to achieve enterprise goals." 

 

Q: What are the most significant initiatives underway to improve medication safety in hospitals?

A: "To me the most significant trend is in moving away from blaming the individual to identifying what actually happened.  This allows the institution and providers to look at near misses as well as reported incidents.  In this way will we get to a point where we can correct process problems and avoid significant patient events."  Gordon continued, "To get beyond the blame game, the culture of healthcare needs to change.  Technology and money alone won't solve the problem.  The process needs to be:  find out what happened, perform root cause analysis, address the root cause, and then implement technology and procedures to correct the system.  Fixing the blunt end avoids issues at the sharp end.  It is rare that the sharp end is the actual cause."

Gordon believes that this cultural change must start in the Board Room and executive suite.  Caregivers know that medical errors are a problem but they need to be given permission to openly talk about the issues in order to make improvements.  "It is the responsibility of senior leadership to support caregivers in addressing system flaws, encouraging near miss reporting, and recognizing that reported incidents will go up as a result."

 

Q: You once wrote, "patient safety is an alignment between the ethical imperative to do no harm and economic realities." How can a hospital administrator weigh the imperative against the economic reality?

A: "First, patient safety should not be viewed as a competitive advantage for hospitals.  Openly sharing safety-related information is critical." Gordon believes that widely sharing experiences and information allows organizations to proactively address system failures that will prevent them from making the same or similar errors.  "A hospital's competitive edge comes from how well it executes the delivery of care and achieves the best possible clinical outcome.  Safety belongs behind the scenes so that the patient perceives only the quality of care he receives and the benefits of restored health."

 

Q: You have shown your support of one IT solution, Barcode—enabled Point of Care (BPOC) medication verification, by joining the board of directors at Bridge Medical.   What drew you to this technology as a means of reducing medication errors?

A: "We have tried to solve IS issues in a global fashion in the past.  For example, the electronic medical record has been promised for years and millions of dollars have been spent to achieve this goal.  However, the technology just hasn't been there.  In addition, it has been difficult to bite off the whole apple from a financial and staff training perspective" said Gordon.

"We know from the IOM report that medication errors are far too common.  Reducing medication administration errors is an ideal place to begin." Gordon sees BPOC as an opportunity for hospitals to begin with a "chunk of the apple" that is not prohibitively costly and yet a crucial part of an overall medication error reduction agenda.  "Introducing a highly focused effort such as BPOC provides a significant step forward that is manageable and achievable.  The implementation of BPOC is relatively simple, easily understood, and can be adapted to the specific institution's needs." 

He went on to note that his support for BPOC grew following a visit to Northern Michigan Hospital in Petoskey, MI, where the Bridge Medical MedPoint system is installed house-wide.  "I was impressed with what I saw at Northern Michigan.  I talked with both nurses and patients who said they felt "comforted" by having the technology in place.  The bedside computer did not distract patients and family members felt reassured that their loved one was receiving the best possible care.  This is a good example of a hospital's competitive edge being found in its execution of a well designed safety program."

 

Q: In your mind, what is going to determine the success of BPOC in the future?

A: "The most significant barrier to the implementation of BPOC is the need for barcodes on all medications.  However, this concern has lessened since the FDA announced its intention to mandate barcoding of all pharmaceutical products over the next couple of years."  Gordon then commented on the efforts of VHA and other group purchasing organizations that recognize barcoding of medications as an essential medication error prevention strategy and have set deadlines for barcodes to be on all drugs purchased through the group.  In response to this sort of purchasing pressure, Abbott Laboratories has stepped forward with a commitment to barcode all of its medications by 2003. 

 

Q: Many contingencies have a hand in current patient safety efforts including the payers and employers through groups like Leapfrog.  Do you believe that these parties can drive healthcare providers to use best practices for safe medication use? 

A: "There is no doubt that these groups will have a definite influence on how institutions go forward.  As will JCAHO.  But, I hope this is not the only motivation" Gordon said.  "Nudges from these groups may effect the speed of implementing solutions but this will not be the main motivation for information systems adoption." Instead, Gordon cited healthcare providers' inherent desire to ensure a safe environment for patients. He asserts that hospitals have wanted to address the medication error problem for years but the industry is just now developing the tools to facilitate broad-based improvement.  "Technology is evolving and human factors research, a relative newcomer to medicine, is now being employed to help us address error issues.  We are no longer willing to accept any level of error and so we are embracing technology like BPOC that allows us to make a difference and regain the trust of the public."

 

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Legislative & Regulatory

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FDA to Set BarCode Requirements

The Department of Health and Human Services (HHS) announced that the Food and Drug Administration plans by April 2002 to propose a rule that would require barcode labels on human drugs and biological products.  The requirement would allow hospitals to take advantage of barcode-enabled point of care (BPOC) technology. Patients would wear wristbands with barcodes that would provide personal information, including the person's ailments or any allergies. Before administering a drug, nurses would scan the label and the patient's wristband, and a computer program would study the information to identify possible risks. (Dow Jones International News)

 

FDA Creates Drug Safety committee

The Food and Drug Administration announced creation of the Drug Safety and Risk Management Subcommittee to the Advisory Committee for Pharmaceutical Science. The 10-member committee of nongovernmental employees--including pharmacists William H. Campbell, University of North Carolina at Chapel Hill; Michael R. Cohen, Institute for Safe Medication Practices; and Stephanie Y. Crawford, University of Illinois at Chicago-is expected to have its first public meeting in the spring.   (ASHP NewsNow)  http://www.fda.gov/bbs/topics/ANSWERS/2001/ANS01127.html

 

HR 3292 medication error technology Funding

Reps. Houghton and Thurman have introduced HR. 3292 as the companion to the earlier introduced Graham/Snowe legislation.  The House bill establishes an informatics grant program for hospitals and skilled nursing facilities to encourage providers to make major information technology advances. In addition, the House and Senate Appropriations bills include a variety of earmarks related to medical errors. 

 

New Jersey Bill for Medication Monitoring

Proposed bill A3771 establishes hospital-based medication monitoring pilot program with $75,000 appropriated. Under this legislation, "The hospital shall establish a model medication ordering and administration system which includes computerized on-line physician ordering; generation of immediate alerts to prescribers and pharmacists; integration with pharmacy inventory and tracking, as well as with the hospital's financial systems; generation of auto-alerts to nurses through small portable devices when medications are due to be administered; integration with barcoding identification of both the patient, by means of a wristband, and the actual medications; and integration with the patient's on-line medical record."   Read the entire bill at: http://www.njleg.state.nj.us/2000/Bills/a3500/3771_i1.htm

 

New Jersey Medical Error Reduction Study

Assembly bill No. 2776 establishes an 18-member New Jersey Medical Error Reduction Study Commission to identify policies and procedures that address the issue of reducing medical errors in both inpatient and outpatient settings to maximize patient safety. The commission is to develop recommendations for a Statewide error reporting system that can be integrated with any federal error reduction programs in effect. The commission is also directed to report its findings and recommendations to the Governor, the Senate and General Assembly Health Committees within 18 months of the effective date of this act. The bill appropriates $95,000 to carry out the duties of the commission and specifies that the commission may contract with academic researchers, information systems analysts or other appropriate persons to assist the commission in carrying out its duties.  (LegAlert)

 

Betsy Lehman Patient Safety Center

The Massachusetts Legislature established the Betsy Lehman Center for Patient Safety to help find ways to reduce medical mistakes. The center is charged with coordinating the work of state agencies that regulate health care providers and institutions. Its purpose is to educate medical providers and conduct research in ways to lessen errors that can kill patients. Sadly, the center didn't receive any state funding because of a budget squeeze this year.  (Associated Press Newswires)

 

JCAHO Medication Use Standards

At its October meeting, the Board of Commissioners approved the field review of revised medication use standards.  The revisions are being made in response to the growing focus on error-reduction efforts for medication usage, and to ensure that the standards reflect contemporary practices. The field review will go out before the end of the year.  For more information, contact Bob Wise, rawise@jcaho.org or 630-792-5890.  (JCAHOnline)

 

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Research

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NPSF Calls for Research Proposals

The National Patient Safety Foundation (NPSF) is calling for Letters of Intent for research proposals that enhance patient safety.  Any official member of a not-for-profit institution in the U.S. may apply.  The awards will be up to $100,000 for projects up to 2 years long. Submission deadline is March 15, 2002.  For more information, please visit the NPSF Web site http://www.npsf.org/

 

Patient Safety:  Leading Trend For Healthcare I.T.

Increased medical error prevention using computerized systems, development of HIPAA-compliant information systems, and need for increased IT spending are some of the main concerns facing healthcare information technology (HIT) professionals over the next five years, according to a study released by the Healthcare Information and Management Systems Society (HIMSS) and sponsored by Superior Consultant Company, Inc. The report forecasts that government and employer demands for patient safety will make the prevention of medical errors through computerized systems a top healthcare IT priority. For more information or to receive a complimentary copy of the publication, call 312-915-9237;.  (U.S. Newswire)

 

Patient Safety: Health Care Not Moving Fast Enough

Despite countless new programs and systems, 92% of responders to a poll taken at a national patient safety symposium believe much more could be done to adequately address and reduce medical errors. Only 16% of attendees believe that the health care community is effectively using technology to assist with patient safety initiatives. Less than half of the respondents, 44%, believe Congress or the federal government needs to get involved in national patient safety efforts. 118 representatives from hospitals, health care organizations, and business and consumer groups from across the U.S. took the poll during the Patient Safety Symposium sponsored by The National Patient Safety Foundation, Partnership for Patient Safety, Premier, Inc., and VHA, Inc.  (Health & Medicine Week)

 

ECRI Medication Safety Tool Kit & CPOE Report

As part of the Regional Medication Safety Program for Hospitals, ECRI is partnering with the Institute for Safe Medication Practices and the Delaware Valley Healthcare Council to create a medication safety solutions kit. The kit includes packs of posters designed to promote specific medication safety practices, a binder designed to help hospitals achieve the program's 16 action goals, and a special report on the acquisition of computerized prescriber order-entry (CPOE) systems.  For more information on the tool kit, contact ECRI's Kathy Pelczarski.  (NPSF listserv)

 

Errors Point to distractions, heavy workloads, and inexperience

According to U.S. Pharmacopoeia, staffers' distractions, heavy workloads, and inexperience are the chief culprits behind medication errors in hospitals. In its study of 6,224 medication errors across 56 hospitals: 40% occurred during administration; 21 %, documentation; 17%, dispensing; 11%, prescribing; and 1%  monitoring.  Most of those errors weren't harmful, even though more than two-thirds weren't intercepted before reaching the patient.  Source: "Database tracks causes of hospital medication errors, by Linda 0. Prager.  (Nursing Management, Volume 32, Issue 10)

 

ISMP: better supervision needed

A recent Institute for Safe Medication Practices' Medication Safety Alert says healthcare professionals don't report errors or near misses at a rate that would be optimal for learning more about their causes. Many caregivers worry about making a mistake and having a mishap held against them; paradoxically, these concerns increase anxiety on the job and the chances of error. To improve safety, supervisors should have better training in interpersonal "people" skills, ISMP says.  For more, go to http://www.ismp.org/

 

California Issues Guidelines for Medication Error Reduction Plans

The State of California Department of Health Services (DHS) has issued guidelines for healthcare providers to comply with Senate Bill 1875 requiring them to adopt a formal plan to eliminate or substantially reduce medication-related errors by Jan. 1, 2002.   A DHS committee has identified principles that healthcare facilities may wish to incorporate into their medication error reduction plans and best practices that have proven to be effective in reducing medication errors.  The five principles are:

1.    Establish a quality system for facility-wide reduction of medication errors.

2.    Develop effective reporting mechanisms to ensure medication-related errors are reviewed.

3.    Establish a baseline assessment and then regularly review the effectiveness of the plan.

4.    Include technology implementation in the medication error reduction plan.

5.    Review pertinent literature concerning medication-related errors to develop the plan.

(PR Newswire)

 

Insulin Near Top In Hospital Medicine Errors

The MedMARx Report, finds that insulin is among the drugs most often involved in errors. From Jan. 1 to Dec. 31, 1999, 56 hospitals reported 6,224 medication errors. These included not giving the patient medicine (the most common error), giving the wrong dose (the second most common error), giving the wrong medicine, giving the medicine at the wrong time, giving an extra dose, and giving the medicine to the wrong patient.

 

AJHP Study: Causes of Fatal Errors

According to a retrospective analysis of fatal medication errors most were the result of improper dosing of the intended drug or the administration of an incorrect drug.  (Am J Health-Syst Pharm 58(19):1824-1829, 2001)

 

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Taking Action

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National Collaborative To Eliminate Medical Errors

In a major initiative to create a national infrastructure to improve patient safety and dramatically reduce medical errors, First Consulting Group (FCG), led the launch of the Patient Safety Institute (PSI) to provide real-time, secure patient information to physicians anywhere in the country.  PSI is a coalition of patients, physicians and hospitals with a mission to save lives, improve care and increase the efficiency of healthcare.

The patient information network announced by PSI will use proven, open-systems-based and commercially available communications technology, as well as proprietary information security technology and business methods contributed by FCG, to provide secure access to patient information at the point of care. Using the technology, physicians will initially gain access to five vital pieces of patient information: medications, allergies, laboratory results, diagnoses and immunizations.  (BusinessWire)

 

Florida Patient Safety Steering Committee

The Florida Patient Safety Steering Committee has produced four Practice Models for Medication Safety in hospitals, which may be accessed in PDF format on their website at http://www.fha.org/pttoolkit.html. Practice Model Guidelines:

+ Safe Medication Ordering/Prescribing Practices for Hospitals

+ Safe Medication Dispensing Practices for Hospitals

+ Safe Medication Administration Practices for Hospitals

+ Safe Medication Monitoring Practices for Hospitals

 

Minnesota approves ATM dispensing Device

Americans have doubled prescription drug use since 1989, yet the number of pharmacists remains about the same.  Understandably, a source of medication error is slip-ups by overworked pharmacists. InstyMeds is the first automated prescription drug dispenser, the latest in a trend toward computerizing prescriptions, to cut not just drugstore lines, but dangerous errors.  The ATM-style technology combines barcode and computerized physician order entry systems to safely fill prescriptions at the touch of a few buttons. Still a pilot project, Minnesota's pharmacy regulators have approved its use anywhere in the state.  (Associated Press)

 

Michigan Organizations Honored

The Institute for Safe Medication Practices (ISMP) presented Blue Cross Blue Shield of Michigan, the Michigan Health & Hospital Association (MHA) and Michigan Pharmacists Association (MPA) with a 2001 Cheers Award.   A medication safety task force of representatives from the MHA, MPA, the Blues and group customers developed multi-year plans that address safe medication practices, including technological and process change components.  The Michigan Blues, MHA and MPA are active in other patient safety initiatives as well.  All three organizations are founding members of the Michigan Health and Safety Coalition, which is a non-partisan group of physician and hospital organizations, labor, health care purchasers and health plans that are examining medical error and patient safety issues in order to improve health care quality in Michigan over the next several years.      (PR Newswire)

 

New Patient Safety Internet Portal

In a joint venture between Children's Hospitals and Clinics of Minneapolis, Partnership for Patient Safety of Chicago (p4ps), and Second Curve Group, Inc. of Cincinnati, a new Patient Safety Intranet Portal service debuted at the 2001 Patient Safety Symposium: Stories of Success on October 10th to 12th in Dallas, Texas. The Patient Safety Intranet Portal allows hospitals to have a state-of-the-art automated online Patient Safety Incident Reporting system available on their own Intranet within a matter of days. Users can automatically track data, spot trends, understand safety themes and access additional safety information related to the specific incident, sentinel event or near miss.  (Westlaw)

 

VA Patient Safety Summit Summary

The 18 months since the publication of the Institute of Medicine's landmark report on the prevalence of medical errors have been busy ones for many federal healthcare agencies. At the US Department of Veterans Affairs (VA), efforts are under way to develop and implement patient safety programs throughout the 173-hospital system. Its National Center for Patient Safety, formed in 1998, has trained more than 1000 VA personnel in root cause and human-factors analysis of adverse events. Representatives from the VA, its Center for Patient Safety, and key federal and private organizations discussed their progress in translating ideas about how to improve patient safety into reality at a conference held in Washington, DC, this September. The meeting offered hands-on strategies to identifying medical errors. The complete conference report: covers several topics including a look at methods for increasing medication safety.   (Medscape Managed Care, 2001)

 

Insurer Pledges Nursing Scholarships

The health insurer Humana Inc. pledged $17,500 in nursing scholarship support if Baptist Memorial Hospital-Memphis meets new medication safety goals.  The effort will focus on specific projects involving proper use of medication. If Baptist's Memphis hospital meets improvement goals in those areas, Humana pledged to fund scholarships for three Baptist nursing students. In the coming year, Humana plans to implement similar partnerships with hospitals in Chicago, Cincinnati, Phoenix, as well as communities in South Texas, Florida and other cities.  (The Commercial Appeal)

 

San Diego Center for Patient Safety

The San Diego Center for Patient Safety (SDCPS) has been established as a collaborative effort between the Veterans Affairs (VA) San Diego Healthcare System and University of California, San Diego Health Sciences. The SDCPS, funded by a $590,000 three-year grant by the Agency for Healthcare Research and Quality (AHRQ, will identify critical patient safety issues, conduct research to reduce the occurrence and severity of medical errors, and educate healthcare providers and patients throughout the San Diego community about patient safety.  (Associated Press Newswires)

 

Hospital Systems Among Baldrige Finalists

Two hospital systems made it to the final stage of the review process for the 2001 Malcolm Baldrige National Quality Award. SSM Health Care and Baptist Hospital Inc. were among 13 applicants from various types of U.S. organizations who made it to the illustrious final round. St. Mary's Hospital in Madison WI, a SSM hospital, has demonstrated its dedication to quality improvement through numerous initiatives including the implementation of Bridge Medical's MedPoint patient safety system at the point of care.  Unfortunately, this was not the year for healthcare and neither system received the Baldrige Award.  (AHA News Now)

 

ASHP Endorses Medication-Use Safety Position

The American Society of Health-System Pharmacists (ASHP) announced the completion of an in-depth analysis for the development of a "medication-use safety coordinator" position within U.S. health systems. The  "Medication-Use System Safety Strategy" addresses medication errors by proposing that either an individual or team be charged with ensuring medication-use safety throughout the hospital or health system.  

 

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BPOC In The News

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Novation Requires Unit-of-Use Barcoding

Novation, the supply company of VHA Inc. and University HealthSystem Consortium (UHC), announced its new guidelines regarding product barcoding.  Promoting unit-of-use barcoding on its contracted products is key to supporting Novation's goals of supply chain efficiency and promoting patient safety.

"Members have told us unit-of-use barcoding is critical to their needs.  Barcoding only the outer shipping carton is not sufficient to aid health care workers.  So, we are taking action.  We are strongly encouraging suppliers to begin adoption of unit-of-use barcoding on all products we currently have on contract." said John Riddick, director of quality assurance and regulatory affairs for Novation.

Novation's white paper outlining its guidelines to both suppliers and members regarding unit-of-use machine readable barcoding is available on its public website, www.novationco.com  (PRNewswire)

 

Virginia Hospitals implement BPOC System

The Danville Regional Health System in Danville, VA, is the first hospital in the nation to implement Med Administration Check (Siemens). In March 2001, Danville deployed the system in a 38-bed acute care unit dispensing 350 to 450 medications each day to urology and nephrology patients. On that one unit, the system has averted an average of 12 potentially dangerous medication errors per month. Danville is nearing completion of the rollout process of Med Administration Check throughout the entire hospital. Mary Washington Hospital in Fredericksburg, VA is also seeing results with the system.

 

Missouri Rehab Center To Install BPOC System

Missouri Rehabilitation Center (MRC), a 136-bed facility, announced its plans to implement a BPOC system. The hospital will install an integrated medication management system with computerized provider order entry, barcode scanning at the bedside, electronic charting, pharmacy and workflow/event management components. MRC is one of the first sites in North America to participate in the American Society of Health System Pharmacists' Foundation (ASHP) failsafe design study.   (Canada NewsWire)

 

System Issues Alerts on 17% of Orders

Alerts occurred on 17% of medication orders in a five-month, eight-workstation pilot test of Bridge Medical, Inc.'s barcode-driven MedPoint system at Sacred Heart Medical Center in Spokane, Wash., said Frederick Galusha, CIO of 26-hospital Inland Northwest Health Services. He said 6.6% of the doses weren't given, presumably because clinicians changed their minds after seeing alerts. "It's unbelievable what we are finding out, and we are a very good hospital," he told the Microsoft Healthcare User Group meeting in San Diego. Based on those results, system savings due to error prevention will far exceed the license fee, he said.   (Inside Healthcare Computing)

 

VA Drive to Mine Medical Data

In a U.S. Veterans Health Administration hospital, a nurse using a barcode device scanned a patient's wristband and a syringe. A nearby computer, linked to the scanner and the hospital pharmacy, confirmed that she was giving the right drug to the right patient. When she touched the screen again, the time of the injection was entered into the patient's record. With technology like this, the VHA is leading a movement to unlock the data lurking in hospitals to help doctors improve patient care and reduce errors. BPOC caught the attention of the VHA former chief, Dr. Kenneth Kizer, during a 1998 visit to the VHA's medical center in Topeka, Kansas. The hospital had developed a prototype that used barcode scanners to match patients, drugs and doctors' orders. At a patient safety conference shortly after his Topeka visit, Dr. Kizer declared that the VHA was going to install the technology in all of its hospitals. By September 2000 the system was operating in 170 hospitals around the country. An in-house study in the Topeka hospital found that the system had reduced medication errors there by 70%.   (The Wall Street Journal, Monday, December 10, 2001)

 

Rhode Island Hospital Creates unique Barcode system

Rhode Island Hospital has devised a new patient-identity system in which patients will be issued a card with their picture and a barcode at their first encounter.  They will present the card at all further interactions, such as preoperative testing. Once admitted, patients will sport a high-tech version of the traditional hospital armband: it displays their photo as well as the barcode. The same photo and barcode appear on the medical record. A nurse and an anesthesiologist will scan both the armband and the medical record before surgery begins. The same scans will be required before tests are done or medication given.    (The Providence Journal)

 

Vermont Hospital Begins ASHP Study

The American Society of Health System Pharmacists (ASHP) Foundation announced its first U.S. healthcare site for its Failsafe Medication Management System Design (F.M.M.S.D.) study. Northwestern Medical Center Inc., St. Albans, VT (NMC) will be the first hospital to actively participate in this project by implementing a comprehensive medication safety system including computerized physician order entry, pharmacist electronic order review, barcode scanning at the bedside, electronic charting and workflow/event management.    (Canada NewsWire)

 

Franklin Memorial Adopts BPOC

Franklin Memorial Hospital in Rocky Mount is one of four hospitals that will test a HIS system that will combine current information systems - including pharmacy, radiology, patient management and accounting systems. Patients will wear barcoded identification bracelets and a BPOC system will make sure the right drug goes to the right patient at the right time. Eventually, the system could be expanded to Carilion Health System's 10 other hospitals in southwest Virginia.   (Associated Press Newswires)

 

Pennsylvania Hospitals Employ BPOC Solutions

The VA Pittsburgh Healthcare System has one of the most advanced computerized prescription ordering systems, established in 1999 as part of a national VA initiative. Recently, the VA enhanced its safety system by installing a barcode medication administration system, in which patients and drugs dispensed in the hospital are given a barcode. When a medicine goes to the patient, the nurse scans the medicine barcode and then the barcode on the patient's wristband. The computer determines whether it is the right medicine for the patient at the right time.

Ohio Valley General Hospital in Kennedy, PA started using a similar system. When nurses deliver medicines to patient rooms, they carry wireless, hand-held scanners. The value is clearly seen when a busy nurse realizes that he or she has brought a medicine to the wrong patient.   (Pittsburgh Post-Gazette)

 

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Cause For Concern

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AHRQ: Elderly Prescribed Inappropriate Medications

A new study from the U.S. Agency for Healthcare Research and Quality (AHRQ) highlights the problem of inappropriate prescribing in elderly patients in the United States. According to findings in the Journal of the American Medical Association  (JAMA), about one fifth of the approximately 32 million elderly Americans not living in nursing homes in 1996 used at least one or more of 33 prescription medicines considered potentially inappropriate. Nearly one million elderly used at least one of 11 medications that should always be avoided in the elderly.   (PR Newswire)

 

Medication Errors Noted Late

Up to 71 percent of medication errors in community-based long-term healthcare facilities are not reported to state health officials on time, according to a Massachusetts state auditor's study. One auditor found that up to 68 percent of serious medication errors, requiring hospitalization, were not reported on time.

(The Boston Globe)

 

Florida Hospital Gives Woman Wrong Drug

Laura Mack, 25, of Palm City, went into cardiac arrest after a drug was incorrectly administered.  Mack went to Martin Memorial Medical Center with hives. She thought she was having an allergic reaction.  One of the drugs she was given -- epinephrine -- should have been injected into a muscle, not into a vein  as injecting the drug is known to cause cardiac arrest. The hospital admitted to making  "a medication error that complicated the patient's condition.'' Fortunately, Mack recovered and was released from the hospital. After Mack's mistreatment, packaging for the allergy drug was changed to make administration instructions more clear. The hospital will also require two nurses to review doctor's orders before administering this "highest-risk'' drug.

 

Overworked Pharmacists Making More Errors

Errors by pharmacists in Connecticut are on the rise as the state and the nation copes with a shortage of pharmacists and increasing prescription drug use. The number of pharmacist errors reported by Connecticut consumers climbed to 75 in 2000. The number of reported errors had hovered around 10 per year through much of the 1980s and 1990s.

A national survey performed last year found that prescription errors surged in nearly every state during the mid-1990s. Industry experts say they see the problem only getting worse. Between 1992 and 1999, the number of retail prescriptions sold in the United States increased 44 percent to about 2.8 million. The number is expected to rise to nearly 4 billion in 2005 while the number of pharmacists is expected to grow only 4.5 percent by 2005. (Associated Press Newswires)

 

M.D. Sues Hospital in Wife's Overdose Death

The wife of a doctor on the staff at Presbyterian Hospital, Albuquerque died Sept. 22 as a result of an overdose of painkilling medications after a routine operation.  A resulting lawsuit points to a lack of communication, contending that the medication order did not state a maximum dose of Demerol and that the nurse giving painkillers in the patient's hospital room did not take into account the drugs that had already been administered in the recovery room. Overall, she received 125 mg of Demerol, 25 mg of Phenergan and 3 mg of morphine during a two-hour period. (Albuquerque Journal)

 

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Grants

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AHRQ career development Grants

AHRQ is interested in funding career development grants to investigators who want to develop their research careers in areas related to patient safety.  It is expected that these projects address key unanswered questions about how errors occur and provide science-based information on what patients, clinicians, hospital leaders, policymakers and others can do to make the health care system safer.  Research results will identify improvement strategies that work in hospitals, doctors' offices, nursing homes, and other health care settings across the nation. Further information about AHRQ's research agenda in this area can be found on the Agency web site at http://www.ahrq.gov/qual/errorsix.htm

 

HHS Announces $50 Million Investment in Patient Safety

HHS Secretary Tommy G. Thompson announced the release of $50 million to fund 94 new projects to reduce medical errors and improve patient safety. Funded by HHS' Agency for Healthcare Research and Quality (AHRQ), the projects will address key unanswered questions about how errors occur and provide science-based information on what can be done to make the health care system safer.  This $50 million research initiative is the first phase of a multi-year effort.  For specific information about all grants and projects, go to http://www.ahrq.gov/qual/errorsix.htm. Several projects specifically target medication errors including:

+ DenverHealth ($244,760) - to examine the effectiveness of computerized provider order entry (CPOE) systems.

+ Research Triangle Institute ($200,000) - to examine the methods of medication data transfer between treatment settings.

+ University of Pittsburgh ($4,845,439) - to evaluate a reporting system for hospital-acquired infections and medication errors.

+ Harvard Pilgrim Healthcare ($8,404,886) - to improve the detection of medication prescribing errors in outpatient settings.

+ Brigham and Women's Hospital ($5,545,748) - to establish a Center of Excellence for Patient Safety at the Brigham and Women's Hospital in Boston.

+ University of Pennsylvania ($6,795,283) - to establish the Center for Excellence in Patient Safety at the University of Pennsylvania.

+ Abacus Management ($99,957) - to create an interactive Web-based education tool to facilitate communication of medication information between elderly patients and their providers.

+ Johns Hopkins University ($1,121,808) - to determine the effect that electronic prescribing has on medication error rates and prescribing practices.

+ Creighton University ($903,480) - to determine the impact of the use of personal digital assistants (PDAs) by prescribers on medication errors in primary care, office-based practices.

+ University of California, Davis ($1,494,255) - to increase patient safety by reducing the incidence of serious warfarin dosing errors in hospitalized patients.

+ Prediction Sciences, San Diego ($99,829) - to use neural nets to develop a PDA-based algorithm to predict optimum medication dosages for treating patients with bipolar disorder.

 

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EVENTS

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BRIDGE MEDICAL SEMINARS TO IMPROVE PATIENT SAFETY

February 14, 2002 in Rosemont, Illinois

February 15, 2002 in Ft. Lauderdale, Florida

February 26, 2002 in Seattle, Washington

 

NATIONAL PATIENT SAFETY FOUNDATION CONFERENCE

April 24-26, 2002, Indianapolis, Indiana.

 

ANNENBERG IV - CHANGING THE CULTURE OF PATIENT SAFETY

April 22-24, 2002 in Indianapolis, Indiana

 

7th EUROPEAN FORUM ON QUALITY IMPROVEMENT IN HEALTH CARE

March 21- 23 2002 in Edinburgh, Scotland

 

NATIONAL INITIATIVE FOR CHILDREN'S HEALTHCARE QUALITY (NICHQ) FORUM

March 12-13, 2002 in Tempe, Arizona

 

AMERICAN ORGANIZATION OF NURSE EXECUTIVES ANNUAL MEETING

April 6-10, 2002 in Orlando, Florida

 

WHAT'S GOING ON?

To keep informed on patient safety related events around the nation visit www.BridgeMedical.com

 

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Bridge News

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NorthEast Medical Center First in North Carolina to Use MedPoint

NorthEast Medical Center (NEMC) Charlotte, NC, has begun implementing the Bridge MedPoint™ system, an innovative patient safety system that uses barcode technology at the patient bedside. Developed by Bridge Medical, Inc., MedPoint is the first barcode-enabled point-of-care system to combine medication and blood product administration verification with laboratory specimen identification.

"Patient safety is our top priority, but today's nurse is very busy managing large amounts of information," says Barry Hawthorne, R.N., Vice President of Patient Care Services. "We were looking for something simple to use that would provide our nurses with the information they need in a timely and efficient manner. Scanning a barcode saves time because it is quick and easy. And while you're scanning, MedPoint takes care of the paperwork, too. It creates an electronic Medication Administration Record (MAR) that replaces the need for a paper MAR."

 

Greater NY Hospital Association Endorses Bridge MedPoint

GNYHA Ventures, Inc., a corporate affiliate of the Greater New York Hospital Association, has endorsed the Bridge MedPoint™ system, a patient safety solution developed by Bridge Medical, Inc.  Under the exclusive three-year marketing agreement, "GNYHA Ventures will promote Bridge's MedPoint patient safety system," said GNYHA Ventures Executive Vice President and COO Lee H. Perlman, FACHE. "Our member hospitals are committed to preventing medical errors and continually improving health care quality and patient safety. This agreement with Bridge will help us achieve this goal."

"Our Medication Errors Workgroup identified BPOC technology as an effective tool in decreasing medication errors and enhancing patient safety at the medication administration phase," explained Perlman. "In view of these findings, we decided to partner with Bridge Medical to make this proven technology available to our members."

 

Hospital Pharmacy Director Reports Success of MedPoint System at ASHP

Roy L. Gryskevich, RPh, MBA, director of pharmacy services at 238-bed Weirton Medical Center, discussed the successful implementation of Bridge barcoding technology to track, reduce and prevent medication errors at the Midyear Clinical Meeting of the American Society of Health System Pharmacists. Held in December in New Orleans, Gryskevich's ASHP presentation focused on Weirton's use of the Bridge MedPoint˘ system for its medication safety initiative and "why barcoding was right for Weirton."

"Preliminary findings indicate MedPoint would have prevented 46 percent of the medication errors that occurred without the system in place. We expect this percentage to increase as lessons learned from MedPoint data help us improve practices and processes, " said Gryskevich.

 

Miami Children's Hospital Safeguarding Young Patients

Miami Children's Hospital, the only licensed specialty hospital for children in South Florida, has always made a point of being "miles ahead" in terms of protecting its young patients.  Now the 268-bed medical complex becomes the first children's hospital in the U.S.-and the first hospital in Florida-to begin implementing the Bridge MedPoint system.

 

Bridge Board member recognized by JCAHO and NCQA

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Committee for Quality Assurance (NCQA) announced the inaugural winners of their Individual Leadership in Patient Safety Awards. The recipients are James Conway of Dana-Farber Cancer Institute, Boston, MA, and Gordon Sprenger formerly of Allina Health System, Minneapolis, MN. The Award was established to recognize excellence in creating and sustaining cultures of patient safety across health care organizations and health plans. Bridge Medical congratulates Gordon Sprenger, a member of the Bridge Medical Board of Directors, on this honor.

 

Bridge Banner Moments

This quarter, several Bridge customers have accomplished some notable milestones.

 

NORTHERN MICHIGAN HOSPITAL in Petoskey, MI, has rolled out the MedPoint system house-wide.  More than 135 beds are guarded by our PC-based system.  In addition, NMH is the first Bridge site to adopt the Bridge eMAR in lieu of their paper Medication Administration Record.  With this development, nurses are using the online e-MAR as the sole medication record eliminating the need for any duplicate documentation steps.

 

SACRED HEART MEDICAL CENTER in Spokane, WA has successfully migrated its pharmacy system to the Meditech Magic system.  MedPoint is interfacing beautifully with the Meditech system thanks to its new interface and all 68 devices have been converted.

 

ST. FRANCIS HOSPITAL in Columbus, GA, went live on the MedPoint system in December and is now operating our devices at 40 beds on two med/surg units.

 

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The Point of Care is published quarterly by Bridge Medical, Inc.

 

Author & Editor: Jamie Kelly

INET: jkelly@BridgeMedical.com

 

Permission to reprint portions of this publication is granted subject to appropriate credit to feature article author and Bridge Medical.

 

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