A woman is admitted to the hospital with a fractured femur and is gven an order for ondansetron (Zofran) for post-op nausea. Her condition worsens with vomiting, headache, diaphoresis and abdominal cramps. After examining the infusing IV bag, the nurse sees that the patient has received another patient's metronidazole (Flagyl). The patient's roommate received her ondansetron.
An assembly line worker at Yamada Electric assembles devices that have two push-buttons. For each device, a spring must be placed under each of the two buttons. The job is repetitive and if the worker is distracted she may forget to put a spring under one of the two buttons causing a defect in the finished product.
The Nature of Error
What do these two errors have in common? More than you might think. First, neither the nurse nor the worker was cognizant of the error that she had made. Both individuals experienced what is known as a "slip" to human factors experts.(1) The nurse mentally transposed two tasks - incorrectly telling herself where she wanted to hang each bag. The worker lost track of where she was in her task, possibly due to an interruption in her work. These slips are an unavoidable fact of human nature. Have you ever walked into a room and forgotten why you went there? Or put the milk away in the cupboard rather than in the refrigerator? We all make these slips from time to time. While generally harmless, slips in the production process cost companies millions of dollars each year. In healthcare, slips in patient care can cost lives.
The good news is that slips are easily managed. In either case, a simple check would have alerted the individual to her slip and avoided the error. For the worker, the solution could be as easy as employing a small dish.(2,3) Preceding each assembly, she would count out two springs from a bin and place them in the small dish. After assembly is complete, but before she passes the device on down the line, she could look at the dish. If a spring remains, an error has occurred. The worker knows a spring has been omitted and she can correct the omission immediately. Likewise, if barcoded patient identification tags had been scanned and matched to each patientÝs medication order before the nurse hung either i.v. bag, the nurseÝs slip would have been caught prior to administration. A barcode-enabled point of care (BPOC) system would alert the nurse with a visual or audible message relaying the patient/medication mismatch. The cost of inspection (looking at the dish or running the barcode scanner) is minimal yet effective. Employing failsafe mechanisms such as these is at the core of the world renowned Toyota Production System (TPS) and a driving force in Japan's remarkable quality improvement success.
This comparison of two quality improvement processes - increased patient safety through medication error reduction and Toyota's quest for lower costs through zero-defect production - evaluates some of the similarities, boundaries and practical applications of TPS' core principles within the medication use process. The intent in highlighting the correlation is to illustrate the potential of BPOC technology in the context of a success story that in many ways has followed a parallel course.
TPS and The Medication Use Process
It is interesting to note that an environmental correlation can be drawn between the climate that gave birth to the TPS after World War II and the current challenges facing inpatient healthcare. The concept of TPS was established in recognition of Japan's lack of natural resources, making the cost of raw materials disadvantageous when compared to European and American countries.(4) To overcome this handicap, it was essential for Japanese industries to produce better quality goods at a lower production cost than those of the other countries. Likewise, the contemporary issue of patient safety is more than a risk management or public relations problem. The U.S. Attorney General's office has estimated that more than $.30 on every healthcare dollar is wasted. Just as it did in the auto industry in the 1980s, improving quality through error reduction can drive down healthcare costs. Reducing error may be the key to resurrecting the financial health of more than 50 percent of US hospitals that operate with less than a 3 percent profit margin.(5)
Another defining factor of the TPS was the need to reduce labor costs in order to be competitive. Toyota employed teams of multi-skilled workers operating highly flexible and increasingly automated machines to produce volumes of products in enormous variety.(4) While we rarely regard our nation's healthcare labor force shortage as advantageous, tight resources may, in part, be credited with creating a highly skilled and flexible nursing profession. Nurses epitomize an ideal multi-tasking workforce able to perform numerous activities and take responsibility for their own process improvement.
One further similarity exists between the TPS ideal and the state of our medication use process today. TPS was designed to forecast based on actual demand(6), that is the number of goods already requested by customers. To determine actual demand, car dealers around Japan send daily reports to Toyota - the resulting data serves as the production requirements for the plants. The ultimate goal of the TPS is to create a production environment capable of delivering a single unit as it is ordered.(7) The philosophy behind "just-in-time" (JIT) production is not to sell products produced, but to produce products to replenish those that have been sold. To do this, JIT production supplies the right parts at exactly the right time and in exactly the right amount at every step in the process. Sound familiar? These are the very principles that shape modern pharmaceutical care. Demand for medications is not forecasted but rather met by a supply based on dynamic orders, patient reactions, lab results and a myriad of other factors. Enormous effort made in the past 20 years has resulted in a pharmaceutical standard of the "unit dose."(8) This factor uniquely positions hospitals to implement many of the quality improvement concepts that have served Toyota so well.
TPS Forces at Play in Medication Administration
The Japanese are good at manufacturing. Just ask any global producer with whom they competed in the 1980s. The competitors will probably tell you how the Japanese captured a large share of the global-market by creating world-class standards in design, materials, and management. How did they do it? They created a comprehensive system built on three core concepts and then honed that system over several decades. These same concepts, illustrated in detail below, may serve healthcare leaders well in improving medication use for optimal patient outcomes.
First, kanban is a simple parts-movement system that enables JIT production of goods by moving parts from one workstation to another on a production line. The essence of the kanban concept is that a supplier should only deliver components to the production line when they are needed, so that there is no storage in the production area.(9) Within this system, workstations only produce/deliver desired components when they receive a card and an empty container, indicating that more parts will be needed in production. This concept is fundamental to American hospitals as evidenced by the effort to remove dangerous and often misused floorstock drugs from patient care areas. Today, round-the-clock pharmacies may be automatically prompted to provide the medications necessary to replenish empty dispensing drawers as needed to fulfill the physicians order.
The second feature of the TPS that can bring immeasurable value to the medication use process is the aforementioned use of failsafe devices known in Japan as poka-yoke. A poka-yoke device is any mechanism that either prevents a mistake from being made or makes the mistake obvious at a glance.(10) The ability to detect a mistake at a glance prior to production means that the error does not reach the customer and the source of error is limited to prior steps in the process. Poka-yoke devices fall into two major categories: prevention and detection.(11) A prevention device engineers the process so that it is impossible to make a mistake at all. In healthcare, we commonly refer to similar conventions as "forcing functions".(12,2) Consider the method employed in anesthesia to eliminate the confusion of oxygen tanks with other gases. Hoses that fit oxygen tanks will not connect to other sorts of tanks, virtually eliminating accidental administration of the wrong gas. A detection device typically warns the user of a problem, but it does not enforce the correction. We are surrounded every day by both detection and prevention poka-yoke devices. A microwave will not work if the door is open (a prevention device). A car beeps if the key is left in the ignition (a detection device). A few years ago, some cars were designed not to start until the passengers had buckled their seat belts (a prevention device); but this mechanism was too intrusive and was replaced by a warning beep (a detection device).(11)
In healthcare as in manufacturing, quality assurance is largely reliant on inspection. Self-inspection relies on the worker to inspect the product he/she processes. Often, the worker may compromise judgments and accept items that ought to be rejected or make inspection errors unintentionally due to fatigue, stress, or other pressures.(2) This is similar to the current expectation placed on nurses to intercept all errors in the medication use process at the tail end of the production chain - during administration. A better technique, successive inspection, provides objectivity.(2) Workers inspect products passed along from the previous operation before processing them on themselves. On average an 80-90%(7) reduction in the number of manufacturing defects can be achieved by adopting successive inspection. Successive inspection techniques have long been used by pharmacists and nurses to intercept as many as 70% of the errors made in the medication use process prior to administration.(13) However, successive checks rely on human factors to detect error and fail to provide rapid feedback when errors occur. When enhanced with a poka-yoke device, the nurse can consistently ensure that proper conditions exist prior to administration.
Finally, the concept of kaizen, meaning continuous improvement, is central to all TPS success and imperative for healthcare organizations to achieve patient safety. Toyota team members are responsible for their own improvement - taught to kaizen their jobs to achieve higher efficiency, better quality and lower costs.(10) This is challenging in the medical environment where inter-disciplinary dependencies are great and errors are passed along through many hands. Politics, power dynamics and ownership issues quickly surface in this environment. However, until quality can be assured at the intermediate steps, mutli-disciplinary teams are necessary to resolve quality issues. When a comprehensive medication management solution is realized, it will address all the components of the process: ordering, clinical checking, transcription, drug distribution, automated drug-dispensing-device interfaces, positive patient/drug identification via barcodes, documentation of medication administration, patient monitoring, charge capture based on administration, supply chain management and error and outcomes analysis.(6) Each step in the process will then be subject to enhanced checks and each discrete team can take responsibility for kaizen related to their daily work.
BPOC Measures Up
Nursing activities such as medication administration are highly responsive to the implementation of poka-yoke devices because most errors made in nursing practice are slips (errors in execution) rather than errors in planning.(1) BPOC systems exemplify technology designed to manage slips in that they do not merely examine administrations after the fact (for example through retrospective chart review). Instead, they provide for before-the-fact, enhanced self inspection whereby errors are intercepted prior to administering the medication. The systems safeguard the bedside, enabling immediate feedback to the nurse. Also, BPOC is designed to stop predefined errors. The dish in the manufacturing example kept the worker from forgetting to insert a spring. It would not detect, for instance, a situation where the worker accidentally dropped a spring on the ground without noticing.(13) What's more, a worker wishing to ignore a spring remaining in the dish could do so. Likewise, a BPOC system is focused on preventing specific errors rather than detecting all possible errors in the medication use process. While the system can provide a "do not crush" warning for certain medications, it cannot ensure that the nurse heeds this warning.
Another parallel between the conventions of the TPS and the design of BPOC technology is the real-time nature of the supplier (pharmacy) to production (nursing) relationship. Just as uninterrupted flow is critical to JIT production, the immediate and accurate response of the pharmacist underlies the quality of every administration. By communicating with the pharmacy information system via a real-time connection, nurses are able to act upon new and modified orders as they enter the system. Future developments in BPOC technology will extend the system's communication abilities to yet another supplier, the laboratory. The result is a computerized version of the kanban system providing clinical information to each caregiver necessary to effectively deliver medication therapies to the patient.
As a detection device, BPOC systems impact nursing behavior by providing visual and/or audible alerts when a potential error is detected. For example, a warning appears on the computer screen when a medication is scanned that, if administered, would put the patient over the safe maximum daily dose limit. Systems may also be configured to provide messages based on, but not central to the medication administration. Much like a car will warn the driver of low oil levels while the car is still operable, a BPOC system may offer a comment that the medication scanned has a sound-alike drug and remind the nurse of the appropriate indication for each therapy. In addition, a well-designed BPOC system will proactively guard against common slips by providing worklists and by clearly indicating one's position in the process flow.
There is one final comparison worthy of comment. BPOC technology is the medical equivalent to aviation's "black-box" recording device. One of the great challenges in the analysis of human error is obtaining enough data to understand how an accident occurred. Computers have the ability to record user actions automatically much the way "black boxes" in airplanes record all vital flight information.(1) BPOC incorporates such tracking features in order to analyze problems when they do occur. This information is critical to carrying out the steps of effective kaizen. When error trends are detected, a plan is established to improve the process. Small-scale changes are carried out and the results are observed and tracked. With these data, hospitals can evaluate the result and determine whether an improvement has been achieved. Without this analysis, little can be known about the impact of error reduction measures. Despite significant hospital investments in information technology, quality management experts cite an "analytical gap" as a major reason that clinical care is not better managed and patterns of medical errors are missed.(6) Additional sources of capital will not become available for information technology investment until more healthcare executives can be persuaded that the business case for care management has real payoff in the form of eliminated "rework" due to sub-optimal patient outcomes and reduced costs of malpractice risks.(6) In response to the medication error problem, the analytical gap is bridged by the implementation of BPOC technology.
Today there is a resurgence of interest among automakers in cost reduction through quality improvement. However, unlike the legendary efforts of Toyota, the current effort is firmly rooted in the American automotive industry and the focus is on tackling the rising cost of employee healthcare. Healthcare benefits saddle US automakers with an exorbitant expense, about $800 to $1,200 per vehicle(14), that foreign competitors often do not carry. From 1999 to 2000, healthcare expenses at General Motors jumped $300 million, to $3.9 billion for coverage of its 1.2 million beneficiaries(17). The situation is escalating as a large number of GM employees are aged 40-54, a life stage when healthcare costs usually peak. That means on top of already high rates of health-care inflation, GM is expecting a surge in healthcare costs that could last for two decades. In response to this situation, GM, the largest private purchaser of healthcare in the nation, has spearheaded an effort to advocate widespread adoption of error reduction practices including the computerization of the medication use process. Where healthcare professionals and government regulators have struggled to do so, automotive employers have offered up viable best practices for improving the quality of care from a most unlikely source - manufacturing.
Association for Manufacturing Excellence: www.ame.org.
Associate Press. The Arizona Republic, Monday, June 11, 2001.
Balakrishnan, R. The Toyota Production System: A Case study of Creativity and Innovation in Automotive Engineering.
Bernstein, Jack. (1984) "GM exec discusses commitment to kanban; system has 'tremendous potential,' he says. (Leonard J. Ricard)" Automotive News, Nov 19, p48(1).
Coile, Russel C. Quality Pays: A Case for Improving Clinical Care and Reducing Medical Errors. Journal of Healthcare Management, Vol. 46, Num 3, May/June 2001.
Felciano, Ramon M. "Human Error as a Toll in Designing Health care Information Systems." Journal Club Talk, February 7, 1995.
Grout, John R. and Brian T. Downs. A Brief Tutorial on Mistake-proofing, Poka-yoke and ZQC. Available at: www.campbell.berry.edu/ faculty/jgrout/ tutorial.html
Jacobs, Raymond A. Just-In-Time (JIT) Production, Ashland University web page.
Leape, Lucian. Systems Analysis of Adverse Drug Events. Journal of the American Medical Association, Vol. 274, No. 1, 1995
Norman, D.A. The design of everyday things. New York Doubleday,1989.
NUMMI, Toyota Production System. Available at:
Ohno, Taichi. Toyota Production System: Beyond Large Scale Production. 1978.
Patel, Ashok. Japanese Management Systems. De Montfort University Web Page
Robinson, Harry. Paper presented at the Sixth International Conference on Software Testing Analysis and Review (STAR'97).
Shiego Shingo, A Study of the Toyota Production System Form an Industrial Engineering Viewpoint, 1989.
Shingo, Shigeo. Zero quality control: source inspection and the poka-yoke system. A.P. Dillion. Portland, Oregon: Productivity Press. 1986.trans.
The New York Public Interest Research Group estimates that New York's pharmacists, physicians and hospitals make more than 3 million medication errors each year, and that 500 deaths are a direct result. Because health care personnel are not required to report prescription errors, the actual totals are unknown. Richard Gottfried (D-Manhattan), chairman of the Assembly Health Committee, said he expects his bill requiring all medical personnel to report errors to pass the Assembly this summer.
New York Sen. Chuck Schumer's bill, the Health Information Technology and Quality Improvement Act of 2001, would allocate $355 million to hospitals nationwide to use toward implementing computerized prescription systems in hospitals. Unlike the Medication Errors Reduction Act of 2001, however, the Schumer bill has no Republican co-sponsors.
Massachusetts State senators Richard T. Moore, Dianne Wilkerson, and Bruce E. Tarr introduced SB571. The legislation would provide payment of a one-time bonus to healthcare providers for the implementation of medical error reduction technology. Funding would go to facilities that certify to the commissioner that they have implemented a comprehensive computerized medication order entry system or other computerized system designed to identify, track and prevent medical errors.
Missouri bill HB620 put forth by Republican Rep. James V. Froelker, requires the Department of Health to develop recommendations on methods of reducing medication errors. "The methods include increasing prescription legibility, developing medication error reporting plans, minimizing the confusion in prescription drug labeling and packaging, and increasing patient education concerning prescribed medications."
The department is required to submit the recommendations to the General Assembly by January 1, 2002.
Bill 6941, introduced before the General Assembly, requires the adoption of a plan to substantially reduce or eliminate medical errors by hospitals, outpatient surgical facilities and outpatient clinics and the establishment of a related reporting system. All healthcare providers must submit a plan to the commissioner for approval.
The Nevada legislature is considering a resolution that directs the Legislative Committee on Health Care to conduct an interim study concerning development of systems for reporting medical errors.
Oklahoma is the first state to provide legal protection to the MedMARx database, which is administered by U.S. Pharmacopeia (USP). Through the database, health care professionals can report anonymously on drug errors and compare anonymously their hospital to others to follow trends and pinpoint problem areas. The new legal protection also applies to USP's Medication Errors Reporting Program, which it runs in cooperation with the Institute for Safe Medication Practices.
Minnesota Gov. Jesse Ventura signed a groundbreaking new law, Senate File 560. The law changes the Minnesota Peer Review Statute, which previously inhibited the exchange of information from one hospital to the next for fear of litigation. In essence, the law will help improve communication between health care organizations and help hospitals learn from adverse events and near misses by allowing hospitals, doctors and medical staff to anonymously report medical errors in a web-based registry that can be aggregated and accessed by other health care professionals and the public.
The state would be able to post accounts of medical mistakes on the Internet under a patient safety bill HB 1895. Hospitals and surgical centers would be required to summarize and post "adverse incident reports" quarterly on a state website, so that health professionals could watch for trends and learn from one another's failures.
Senate Bill Takes on Medication Error Reduction
Sens. Bob Graham and Olympia Snowe introduced the Medication Errors Reduction Act of 2001 (S.824) that would give hospitals and skilled nursing homes $97.5 million in grants from 2002-2011 to offset the costs of error-reducing technology. Health care facilities would have the option of choosing between a myriad of available error-reducing technologies, including computer physician order entry, bedside verification through the use of bar codes and use of a hand-held computerized scanner, electronic medical record systems, and automated pharmacy dispensing systems.
HHS Task Force to Improve Patient Safety Standards
HHS Secretary Tommy Thompson announced the establishment of a new Patient Safety Task Force within HHS that will coordinate a joint effort among several agencies to improve existing systems to collect data on patient safety. To fund this effort, HHS' fiscal 2002 budget proposal includes up to $72 million, an increase of $15 million over FY 2001.
Website on Medical Mistakes
The Patient Safety Task Force introduced by HHS Secretary Tommy Thompson will spearhead the implementation of an Internet-based reporting system to minimize the burden of reporting adverse events and errors. The Centers for Disease Control and Prevention and the Food and Drug Administration will provide data on medical errors while the Agency for Healthcare Research and Quality will analyze the causes of medical errors. President Bush is asking Congress for $12 million in start-up money for the medical-error reporting system, which, officials say, is part of a larger effort to reduce medical mistakes. n The Washington Post
Non-governmental initiatives to disseminate health care quality comparative data and develop medical error reduction strategies are being encouraged by state agencies as well as Congress and the federal government. HHS' Agency for Health Care Research and Quality is developing a website - "talkingquality.gov" - that will publish a workbook for entities interested in developing health plan comparative information websites and publications. The site is expected to be operational soon.
Testimony on New Technology
Some senators are calling for nearly $1 billion to help hospitals and technology companies invest in devices to avoid more deaths and injuries. Products demonstrated during a hearing for the Senate Special Committee on Aging included Pharmacy dispensing robotics, barcode enabled point of care systems, computerized documentation, talking pill bottles, and others. n Health News Daily, Volume 13, Issue 112
Secretary Thompson Testifies Before Senate Committee
In his testimony to the Senate HELP committee, Sec. Thompson pointed to the inadequate systems of care that result in approximately $29 billion in excess healthcare expenditures and lost productivity each year. He then offered up what he calls a "very promising way to improve healthcare safety."
"First there's great potential for using the bar-coding technology, so prevalent in our society today, as an effective safeguard against medical mistakes. Doctors and nurses would be able to scan the barcode on a bracelet worn by a patient to monitor what medications they are [giving] and effectively administer those medicines to those patients. Grocers and everybody [who has] been in a checkout line has watched this technology record our purchase of over the counter drugs. And this simple technology could be used to track the dispensing and the usage of pharmaceuticals to prevent mistakes. Simple human errors would be curtailed significantly. Bar coding would also reduce stress on overworked nurses and provide real cost savings."
Cohen Testifies Before house
Michael R. Cohen, president of the Institute for Safe Medication Practices (ISMP) testified before the Subcommittee on Health of the House Committee on Ways and Means Hearing on Medicare Reform. Mr. Cohen said that purchasers of pharmacy services payers - including Medicare - should require providers to comply with standards most likely to enhance medication safety including the effective use of technologies such as robotics, bar coding of pharmaceuticals and computerized prescriptions. He encouraged the creation of incentives to reward healthcare organizations that adopt technology known to reduce medication errors.
The Joint Commission on Accreditation of Healthcare Organizations last week alerted nearly 19,000 hospitals, clinics and nursing homes to the potentially life-threatening consequences of mixing up similar-sounding brand and generic drug names. To help reduce the number of incorrect prescriptions, the commission advised health-care organizations to make sure that prescriptions include the purpose of the medication; that all drug labels include both the generic and brand name and that patients receive written information about their medications that includes the brand name and generic name.
n Los Angeles Times, Monday, June 4, 2001
Since February 1998 JCAHO has published the Sentinel Event Alert to provide important information about the occurrence and management of sentinel events in accredited organizations. Since January 1, 2001, JCAHO has required organizations that seek accreditation to proactively address all issues covered in the Sentinel Event Alert in an effort to prevent similar occurrences in their own organizations. JCAHO expects healthcare organizations to address suggestions made in future issues of Sentinel Event Alert within 45 days of the publication's release. So far, there have been five Sentinel Event Alert publications that deal with medication error reduction and ISMP has contributed to the content of each:
May 2001: Look-alike, Sound-alike Drug Names
February 2001: Mix-up Leads to a Medication Error
November 2000: Infusion Pumps: Preventing Future Adverse Events
November 1999: High-Alert Medications and Patient Safety
February 1998: Medication Error Prevention - Potassium Chloride
A future issue is expected to deal with dangerous abbreviations. n ISMP Medication Safety Alert! Volume 6, Issue 13
Beginning July 1st, hospitals will be required to tell patients when they've been victims of medical errors under new safety standards put forth by the Joint Commission on Accreditation of Healthcare Organizations, a nonprofit group that monitors nearly 5,000 hospitals nationwide. Under the guidelines, hospitals that don't discuss harmful mistakes with patients and fail to prove to commission investigators that they're doing so will risk losing their accreditation. To aid in meeting this standard, Congress is calling for nearly $1 billion to help hospitals and technology companies invest in devices to avoid medical errors. n Detroit News
In a recent paper The Agency for Healthcare Research and Quality (AHRQ) describes various ways to reduce and prevent Adverse Drug Events (ADEs). This paper summarizes research funded by AHRQ, and outlines topics for new research. Some interesting findings include:
Patients who experienced adverse drug events (ADEs) were hospitalized an average of 8 to 12 days longer than patients who did not suffer ADEs, and their hospitalization cost $16,000 to $24,000 more.
28% to 95% of ADEs can be prevented by reducing medication errors through computerized monitoring systems.
Computerized order entry has the potential to prevent an estimated 84 percent of dose, frequency, and route errors.
Hospitals can save as much as $500,000 annually in direct costs by using computerized systems.
A recent study published in the "Journal of the American Pharmaceutical Association" updates a 1995 estimate of $76.6 billion for the annual cost of drug-related morbidity and mortality resulting from drug-related problems (DRPs) in the ambulatory setting. This study updated Johnson and Bootman's 1995 cost-of-illness model assessing the morbidity and mortality associated with DRPs. Since 1995, the costs associated with DRPs have more than doubled to an estimated annual average of $177.4 billion.
The National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) has revised the Index for Categorizing Medication Errors. This update of the 1996 Index considers factors such as whether the error reached the patient and the severity of harm to the patient. Its primary purpose is to help track medication errors in a consistent, systematic manner.
One-third of 800 nurses surveyed said patients in their units missed medications or had them delivered late at least once a week. Eight percent said wrong dosages or drugs were given to patients each week. The survey was conducted by a polling company for the Service Employees International Union, amid a push for federal action to combat the nursing shortage. n The Atlanta Constitution
In a new survey sponsored by the Robert Wood Johnson Foundation of 1,000 medical workers, 95 percent of doctors said they had witnessed serious medical errors. The physicians and a sampling of nurses and executives gave the nation's Medicare system mediocre ratings overall. 61 percent of health care providers surveyed said they accept common errors as routine practice. Just 42 percent said the care is "very good" or "excellent." One in five rated it poor to fair. Four of five agreed that fundamental change was needed and one in 10 favored a complete overhaul of the health care system. To jump-start a solution, the RWJF will spend $20.9 million over three years to fund projects by hospitals and doctor groups to improve health care.
The Institute of Medicine issued a new publication "Envisioning the National Health Care Quality Report,"outlining its vision for the first annual report on the quality of healthcare in the United States. The report, to be issued sometime in the next three years by the Agency for Healthcare Research and Quality, should be tailored to specific audiences, highlighting health care quality achievements as well as shortcomings, and serving as a barometer to gauge progress toward improving the health care delivery system's performance.
According to a study in the Journal of the American Medical Association, potentially harmful medication errors are three times more common among hospitalized children than adults. In a six-week study at Children's Hospital in Boston and Massachusetts General Hospital for Children, 616, or 5.7%, of 10,778 medication orders contained errors, the majority of which occurred when physicians wrote the orders. The overall error rate was similar to those found in previous studies of adult hospitals, but the number of potentially harmful errors was three times greater. The study authors say the results underscore the value of developing technology-based strategies to help prevent medical mistakes. The researchers noted "Despite a comprehensive multidisciplinary approach to data collection, we probably failed to detect some errors, particularly administration errors detected by trained observers following nurses during routine patient care."
n Modern Healthcare
The American Academy of Pediatrics (AAP) now has new recommendations on how to protect children from medical errors in a new policy statement entitled, "Principles of Patient Safety in Pediatrics". The AAP urges health care organizations to take into account the issues unique to pediatric patient safety. To lessen errors, the nation's pediatricians call for more research into how information technology can improve patient safety, since computerized ordering of medications has been shown to decrease errors.
n June issue of Pediatrics
The Pennsylvania Patient Safety Collaborative (PPSC) was officially launched in May. The collaborative is a network of 24 organizations representing health care providers, insurers, organized labor, private industry, and consumers whose goal is to address the systematic issues that lead to medical errors and to work to reduce patient injury from errors through identification and correction of the causes of medical errors. Last month, the PPSC released a monograph -- "Elements of a Culture of Safety."
Representatives from a number of diverse organizations and health care professionals have been meeting since May 2000 to consider methods to improve patient safety and reduce medical errors in Wisconsin. Initial discussions focused on patient safety initiatives in hospitals, extended care facilities, nursing homes and other health care facilities.
A 13-member task force appointed by Governor George H. Ryan to examine issues related to patient safety in Illinois reported its findings and recommendations for improving the Illinois health care system. According to the report, one area that requires further review is the consideration of the issues surrounding the automation or computerization of systems to increase patient safety. Specifically, the task force identified a need for the state to take steps to demonstrate a commitment to build an information infrastructure that supports health care delivery with the "goal of eliminating most handwritten clinical data by the end of the decade."
New York Public Interest Research Group (NYPIRG), the Center for Medical Consumers and the Statewide Senior Action Council of New York State have teamed up to call for statewide legislation that would help eliminate pharmacists' dosage mix-ups and confusion over similarly named drugs by mandating computerized prescription ordering and dispensing systems in all hospitals, doctors offices and clinics.
n Times Union Albany, NY
American Pharmaceutical Partners, Inc. (APP), a supplier of specialty
injectables in the U.S. is taking a leadership role in the efforts to reduce
medication errors with plans to introduce bar codes for all sizes of
products. Currently, all of APP's
products packaged in 50 mL or larger vials incorporate a bar code on the
individual vial. Going forward, APP's plan is to bar code new products, even
individual vials as small as 2 mL. These products can be easily read by most
scanning systems currently available.
"Since it appears that bar code technology may eventually be universally
required in most healthcare facilities, our bar coded injectables will
facilitate the adoption of this important technology," said Jeffrey Yordon,
Chief Operating Officer of APP.
Joining a growing number of health plans nationwide, Blue Cross and Blue Shield of Massachusetts and Tufts Health Plan have hired companies with sophisticated computer software to search patients' insurance claims and pharmacy records to identify those who are not receiving, or may not be obeying, the best medical treatment for their condition. Armed with lists of potential medical errors, medication conflicts, and cases of noncompliance, company or HMO nurses will call these patients or their doctors and try to persuade them to change. n The Boston Globe
The American Society of Health-System Pharmacists House of Delegates met this past June to discuss the use of machine-readable coding. As a result of this discussion, the Council issued a declaration of the following:
The identity of all medications should be verifiable through machine-readable coding technology;
ASHP will support the goal that all medications be verified before they are administered to patients in the inpatient setting;
ASHP will urge 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.
The Council members expressed skepticism that the pharmaceutical industry would act without a mandate from FDA. Still, it is believed that the profound improvements in patient safety that machine-readable coding can offer necessitate the creation of a stronger policy statement promoting the adoption of this technology.
As part of the Patient Safety Initiative launched last February, CHIM and its corporate partners (3M Health Information Systems, Eclipsys Corp., ePhysician and Per-Se Technologies) will gather data from technology vendors and healthcare institutions to build an impartial picture of how information technology can help reduce medical errors in both ambulatory and inpatient settings. A CHIM task force is forming an Advisory Board that will evaluate performance data submitted in case study format. n Managed Healthcare Executive, Vol. 11, Issue 3
In order to expand and share its knowledge of safety practices, the Institute for Safe Medication Practices sponsored a medication safety contest. The winning entry in the category Job Description for a Medication Safety Practitioner went to Covenant Health Systems in Lubbock, TX, for its position, "nurse specialist, medication administration." n Nursing
In June, a select group of organizations from around the world began to work intensely with expert faculty to rapidly implement the world's best ideas for improving patient safety. The goal of the "Quantum Leaps in Patient Safety: Redesigning Culture and Processes of the Medication System" project is to deploy a medication system that is safer by a factor of ten. Through this collaborative, participating organizations will redesign core processes of their medication delivery system.
The National Quality Forum's project to develop a list of "never events" is nearing completion for external review. Never events are adverse events that are so apparently preventable that it can be legitimately presumed that they are the result of an error or mishap. The project seeks to identify measures that can be adopted by states as they develop patient safety reporting systems. The "Never Events" project is funded by the Agency for Healthcare Research and Quality and the Health Care Financing Administration.
Overdose Kills Girl at Children's Hospital
A 9-month-old girl died after a misplaced decimal point caused a Children's Hospital nurse to administer a massive overdose of morphine, illustrating a problem that plagues hospitals nationwide. Children's Hospital officials said that, instead of two 0.5 milligram doses of morphine, a narcotic prescribed to control postoperative pain, the child was given two doses of 5 milligrams each -- 10 times the amount the surgeon intended. The doses were given two hours apart as the girl recovered from successful surgery that day. Officials said the girl did not exhibit a reaction until hours later. The medication error consisted of three consecutive mistakes by a physician, a transcriber and a nurse.
A surgeon wrote a postoperative order for 0.5 milligrams of morphine if needed in the judgment of the nurse. The dosage was correct but the order did not follow a protocol requiring a zero to precede the decimal point, so that it would have read "0.5 milligrams." The order was transcribed by a unit clerk whose handwritten notation on a temporary medication administration record failed to include a zero or decimal point, so that it read "5 milligrams." The nurse tending the child on a medical-surgical floor followed the order without question and injected the morphine into the girl's intravenous line. n The Washington Post
In what is the highest malpractice payout in Cook County Hospital history, county officials have approved a $12 million medical malpractice settlement stemming from an error that has left a 42-year-old woman with severe brain damage.
When the woman was admitted to County Hospital suffering from burns, a nurse administered a dose of potassium phosphate that was five times stronger than the attending physician had prescribed. The medication stopped the woman's heart for 35 minutes before doctors revived her.
According to records, the nurse calculated the medication dose as ordered by the doctor. She then checked her calculations with a colleague and was advised, incorrectly, to add more potassium phosphate. After preparing a solution that was almost five times more concentrated than ordered by the physician, she administered the medication through an intravenous drip. And instead of dispensing the dosage over the usual four- to six-hour period, the IV was incorrectly calibrated to deliver the concentrated dosage in about one hour. n Chicago Tribune
An Alameda County California jury issued a $1.5 million ruling that will forever change the way healthcare providers view the legal significance of effective pain care for the terminally ill. The case called Bergman v. Eden involved care provided to William Bergman, an 85-year-old Californian dying of lung cancer. Mr. Bergman was admitted to Eden Medical Center in Northern California complaining of intolerable pain. After five days in the hospital, where nurses charted pain levels ranging from 7-10, Mr. Bergman was discharged to die at home, still in agony. His family ultimately consulted another physician who prescribed proper pain medication and Mr. Bergman finally obtained relief before he died in hospice care. "This is an important victory for advocates of pain care. Physicians have under treated pain for a very long time with no accountability," said Kathryn Tucker, Director of Legal Affairs for Compassion in Dying Federation. n AP/Seattle Post-Intelligencer
According to a legislative audit, the Wisconsin Department of
Corrections complies with fewer than half of the national prison health care standards.
Among the audit findings an interesting fact surfaced. At most prisons, prescriptions are
distributed by corrections officers who receive only four hours of training on
what they are handling and what the effects of the drugs could be.
n The Milwaukee Journal Sentinel
A recent survey of over 600 school nurses found that during the previous
year nearly half reported errors in giving the students their medications.
Eighty percent reported missing a dose. Other errors included double dose
(23%), giving a drug without permission (21%), and giving the wrong medicine
(20%). Only a quarter of the nurses
said they always gave the medicine to the students. The rest delegate this
responsibility at least some of the time to unlicensed personnel -- most of the
time the school secretary.
n Pediatrics for Parents, ISSN: 0730-6725; Volume 19; Issue 3
HHS Secretary Tommy Thompson issued a government-wide plan to streamline grants programs to make it easier and less costly for grant recipients to work with the federal government. Elements of the plan would reduce the amount of data required for grant applications and reports, reduce the number of required forms, and incorporate new technology and electronic processes into the grants process to reduce paperwork. HHS awards roughly half of the $325 billion in grants issued each year under more than 600 federal programs.
The Institute for Healthcare Improvement and the Robert Wood Johnson Foundation launched a $20.9 million initiative aimed at reducing medical errors. The "Pursuit of Perfection" program will provide grants to 12 institutions to design error-free systems. The funding was announced on the heels of a survey released by IHI and sponsored by RWJF showing that some 61% of health care providers accept common medical errors as routine practice.
Up to $1.5 million will be awarded by the Agency for Healthcare Research and Quality to fund the first-year costs of four to seven projects that demonstrate and evaluate innovative approaches to educating health care providers, disseminating the results of patient safety research, and promoting awareness of the need to improve safety.
The Agency for Healthcare Research and Quality (AHRQ) has announced plans for $7.5 million in research grants that will examine the effect of working conditions on healthcare workers' ability to provide safe, high-quality care. AHRQ is seeking applications that will explore the relationship between working conditions that affect healthcare workers and the safety and quality of care they provide, and test innovative approaches to working conditions that have been effective in improving the quality of a product or service other than healthcare.
Premier Partnership Symposium 2001: Patient Safety
October 10-12, 2001 - Dallas, Texas
Hosted by the Partnership for Patient Safety (p4ps) and co-sponsored by Premier, Inc. and VHA Inc., this conference is a collaboration among organizations that are working to design and support the safest possible healthcare systems.
Health Forum's Summit 2001 - The Leader's Edge
July 29 -August 1 - San Diego, CA
Health Forum's Summit 2001 offers knowledge and ideas to help hospital executives meet organizational challenges and opportunities head-on.
Melior Conference on Error Reporting
July 27 - Needham, MA
"Medical Error Reporting: Saving Patients, Saving Money by Discussing the Undiscussable," is a conference on ways to stimulate, use, and benefit from increased reporting. For more information, contact: Ken Farbstein at 781-444-5525.
New Frontiers in Patient Safety
August 2-3 - Tampa, FL
The Florida Society for Healthcare Risk Management (FSHRM) will present "New Frontiers in Patient Safety." For more on the program, call the Florida Hospital Association (FHA) at (407) 841-6230.
Patient Safety: Disclosure and Defense
September 13 - Fort Worth, TX
The North Texas Society for Healthcare Risk Management (NTSHRM) will present "Patient Safety: Disclosure and Defense." Contact Teresa Giles, at (214) 989-2179.
Patient Safety through six sigma
September 24-25 - San Francisco, CA
This conference has been developed for senior executives and quality professionals who are in the process of implementing statistical tools and methods for quality improvement in their healthcare organizations.
A recent study of barcode-enabled point of care (BPOC) technology used in the healthcare industry shows that the use of BPOC systems has resulted in a 65 percent to 74 percent documented decrease in medication errors.
Published in April 2001 by Bridge Medical, the study is the first comprehensive literature review dedicated to BPOC systems, and shows that use of the technology in medication administration has been demonstrated to be an effective tool in decreasing medication errors and enhancing patient safety. n Business Wire , Publication date: 2001-05-29
Bridge Medical formalized a partnership with Healthcare-ID Inc. to expand the capabilities of the Bridge MedPoint system to include verification of blood transfusions and laboratory specimens. Now, through the integration with Healthcare-ID's proprietary software, the MedPoint system offers transfusion verification and specimen tracking to health care providers.
Healthcare-ID's transfusion verification system works to assure that the patient receives the correct typed and cross-matched unit of blood. Prior to beginning a transfusion, the bar code ID on the patient bracelet is scanned by the health care professional to assure the match between patient and blood product, verify the unit number and compare patient/unit compatibility. Additionally, the software captures the patient's vital signs before, during and at the completion of the transfusion, and documents patient reactions to the transfusion. Data also is provided for the transfusion management reporting system and patient charting. The specimen tracking program from Healthcare-ID 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 health care professional scans the patient's bracelet and prints out the appropriate specimen container labels at the bedside. The increased accuracy results in fewer redraws for patients and speeds processing once the specimen is received in the lab.
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.
"The Bridge MedPoint system can be a valuable solution to hospitals as they work to meet the new JCAHO patient-safety standards," said John Grotting, president and CEO, Bridge Medical. "The Bridge MedPoint system takes the blame out of medication management by providing hospitals with the tools they need to intercept errors and eliminate the system flaws that are the root causes of errors."
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," continued Grotting. "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. MedPoint automatically creates the Medication Administration Record or Blood Transfusion Record, eliminating repetitive and time-consuming tasks for nurses, and generates reports that allow hospitals to identify and eliminate system flaws.
Reporters for Eye on Info, a special supplement of Modern Healthcare, spent three months researching the medical-error problem and interviewing key managers at 14 healthcare organizations that have begun addressing the problem. They found that quality-focused hospitals were able to streamline clunky processes and better direct the action within the hospital, saving time and money while operating more safely.
In an article entitled "Drug delivery fraught with risks" by Jeff Tieman, Eye on Info features the success of Northern Michigan Hospital and the Bridge MedPoint system.
In an article called "Quality is a Business Strategy", HealthTrends editor, Russ Coile, cites the outstanding work of Sacred Heart Medical Center in Spokane, WA. The article reads: "Working with Bridge Medical, a San Diego-based firm that provides error reporting software, the hospital believes that 10-15 percent of its operating costs involve duplicative rework and complications caused by adverse events, as much as $40 million to $50 million at Sacred Heart. Bridge Medical estimates a savings of over $1.6 million at the hospital annually by addressing the problem of medication errors."
Bridge Medical, Inc. welcomed Terance Kinninger as Chief Financial Officer, Senior Vice President of Business Development. Mr. Kinninger comes to Bridge with over 17 years of executive financial and operational management experience in high growth technology companies. He has worked with both publicly held and venture capital backed software companies. Most recently he was Senior Vice President and Chief Financial Officer of WebSideStory Inc., an applications service provider.
Bridge Medical Inc. announced that Gordon Sprenger, president and chief executive officer of Allina Health System, has been elected to Bridge's board of directors. Mr. Sprenger is past-chairman of the American Hospital Association board of trustees and past board chair of Voluntary Hospitals of America.
"Bridge's technologies and services will be a tremendously valuable resources for health care providers," Sprenger stated. "If we're serious about eliminating error, we have to provide the support the people delivering care need to prevent error. Bridge's bar-code and networking technology brings powerful new resources to the bedside."n Business Wire
Get your copy today!
In an effort to carry a message to healthcare executives, payers, regulators and other healthcare decision makers Bridge Medical published a 20-page literature review, "The Effect of Barcode-Enabled Point of Care Technology on Medication Administration Errors". The industry has embraced this paper as a practical guide to BPOC technology. The review describes the features, implementation barriers and documented success of BPOC systems as reported by numerous researchers and hospitals.
To receive a copy, please contact
Bridge Medical at (858) 350-0100 or access the paper online at
Join The Point of Care Listserv Today
The topic of medication safety is at the center of medical, congressional and consumer discourse today. As a result, there is a wealth of information available to you with just the click of a mouse key. In our e-mail version of The Point of Care, we have taken the time to locate the resources for you and will provide web links to all relevant materials and sites whenever possible. A hardcopy newsletter simply cannot deliver such convenience to your fingertips.
Bridge Medical is pleased to provide the medication error community with The Point of Care at no charge. To streamline our quarterly publication and to offer you the most complete resource possible, we have established an online subscription service for our e-mail version of the newsletter. Please take a moment to sign up for this service. Hardcopy distribution of The Point of Care will be limited going forward so reserve your e-copy now ˝ subscribe online!
Subscribing is simple. Visit www.MedErrors.com and follow the instructions. We require only your name and e-mail address, both of which are kept confidential and used solely to distribute The Point of Care.
There are plenty of reasons to trade the familiar pulp-based medium for the electronic word. It's environmentally friendly, financially responsible, and an administrative convenience. Most importantly, an e-newsletter can deliver far more value to you, the reader. Subscribe today.
If you prefer, call us at 1-800-350-0100 or email us at email@example.com and we will be glad to sign you up. Simply provide your name and e-mail address.