******************************************************
THE POINT OF CARE
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A Quarterly Progress Report on America's Other Drug
Problem(TM), Volume 2,
Issue 2 - Summer 2002
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CONTENTS
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LEGISLATIVE & REGULATORY
RESEARCH
TAKING ACTION
BPOC IN THE NEWS
CAUSE FOR CONCERN
GRANTS
EVENTS
BRIDGE NEWS
**NEW** CASE STUDY OF BPOC ERROR PREVENTION
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LEGISLATIVE & REGULATORY
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FDA BARCODING RULE DELAYED
The FDA committed to issuing proposed regulations
requiring bar coding on
all prescription drug labels by April 2002. The May 13th
Unified Regulatory
Agenda indicates that FDA now anticipates the issuance of
the proposed rule
in November of this year. There is speculation that the
agency will gather
public comments before issuing the proposed regulation.
SEC. THOMPSON CALLS FOR BPOC
In nearly identical phrasing to the comments Thompson
made last year, HHS
issued a press release in March reiterating Thompson's
support for BPOC.
"Bar coding offers real promise", Thompson
states. "For example, physicians
and nurses would be able to scan the bar code on a
bracelet worn by a
patient to monitor what medications he or she is getting
to help effectively
administer medicines and track all the medicines the
patient receives."
Thompson went on to say that not only will such a system
alleviate some of
the work-related stresses that nurses face, but BPOC
could also reduce
medical costs.
Link: http://www.hhs.gov/news/speech/2002/020323.html
HOUSE HEARING ON MEDICAL ERROR
On May 8th, The House Energy and Commerce Subcommittee on
Health held a
hearing,
"Reducing Medical Errors: A review of Innovative Strategies to
Improve Patient Safety". The following individuals
gave testimony by
invitation:
+ Ken Freeman, representative, Healthcare Leadership
Council
+ James Hethcox, vice president, Pharmacy Practice,
Cardinal Health, Inc.
+ Dennis O'Leary, president, Joint Commission on
Accreditation of Healthcare
Organizations;
+ Roger Williams, U.S. Pharmacopoeia
+ Bonnie Westra, American Nurses Association
Experts testified that medical errors could be reduced
and prevented by
investing in new technology and maintaining adequate
staffing levels and
training. Ken Freeman cited Abbott's development of a
pre-filled, barcoded
syringe that automatically programs infusion pumps,
Baxter's Point of Care
System combining medication bar-coding and wireless
technology to ensure
patient safety at the bedside, the BD Rx System that
helps prevent
misidentification of specimens at the point of collection
with bar code
enabled computer technology and commended Merck &
Company for placing
National Drug Code barcodes on virtually all hospital
unit-of-use products
to aid hospitals choosing to use drug identification
technologies.
Link:
http://energycommerce.house.gov/107/ram/05082002health.ram.
TRI-PARTISAN PATIENT SAFETY BILL
Sens. Bill Frist and James Jeffords introduced Senate
Bill 2590 the week of
June 3 aimed at curtailing the number of medical errors
in U.S. hospitals.
The bill would offer protection [from lawsuits] to
encourage nurses and
doctors to be more apt to report errors.
Sen. Edward M. Kennedy had been working with Frist and
Jeffords on related
legislation but has not signed onto the forthcoming bill.
Kennedy has
expressed concerns that the bill's legal protections for
error reports were
too broad.
(The Bureau of National Affairs, Volume 7 Number 106)
Organizations that came out in support of the Bill
include:
∑ The
American Hospital Association - Link: http://www.aha.org
∑ The
Department of Health and Human Services Link:
http://www.os.dhhs.gov/
∑ The
American College of Physicians Link:
http://www.acponline.org/index.html
∑ The
American Association of Health Plans - Link: www.AAHP.org.
PATIENT SAFETY HOUSE BILL
Rep. Nancy Johnson introduced The Patient Safety and
Quality Improvement Act
H.R. 4889), a companion to Senate patient safety bill
S.2590.
Link:
http://thomas.loc.gov/cgi-bin/query/z?c107:H.R.4889:
MEDICATION ERROR PREVENTION ACT OF 2002
Bill 4673 was introduced by C. Morella of Maryland on May
7th. The
Medication Error Prevention Act of 2002 seeks to amend
the Public Health
Service Act to provide for voluntary reporting of
medication error
information in order to assist appropriate entities in
developing and
disseminating recommendations with respect to preventing
medication errors.
According to the Bill, U.S. Pharmacopeia's MedMARx
internet-accessible
medication error reporting program would be adopted as a
national voluntary
error tracking system.
Link:
http://thomas.loc.gov/cgi-bin/query/z?c107:H.R.4673:
KENNEDY BACKS CPOE, INTERNET BILL
Sen. Edward Kennedy on June 18 introduced S. 2638, the
Efficiency in Health
Care Act, to encourage the use of Internet technology in
health care and
mandate computerized physician order entry systems for
writing
prescriptions. The bill sets standards for physicians
ordering prescription
medications.
Link: http://thomas.loc.gov/cgi-bin/query/z?c107:S.2638:
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RESEARCH
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8.1 MILLION HOUSEHOLDS REPORT MEDICAL OR DRUG ERROR
More than one in five American families, about 8.1
million households,
report that they have experienced a medical or
prescription-drug error that
turned out to be very serious, according to a survey by
the Commonwealth
Fund entitled "Room for Improvement: Patients Report
on the Quality of Their
Health Care."
+ 16% received the wrong medication or wrong dose at a
pharmacy or while
hospitalized
+ 33% of reported prescription errors occurred while in a
hospital
+ 51% of reported errors stated that the problem was very
serious
+ 22 % reported that the error turned out to be a very
serious problem
Link: http://www.cmwf.org/
I.T. MAY HELP HOSPITALS ADDRESS NURSING SHORTAGE
The implementation of information technology at hospitals
can help improve
the quality of care delivered by and productivity of
nurses, according to a
report released by the California HealthCare Foundation
and First Consulting
Group. The report, titled "The Nursing Shortage: Can
Technology Help?" found
that hospitals must adopt strategies -- such as the
implementation of IT
systems -- to increase nurse productivity, effectiveness
and satisfaction to
lessen the impact the nursing shortage could have on
patient care. The
report highlighted technologies used by hospitals to
support "better and
more productive nursing care" including
barcode-enabled medication
administration, clinical decision support, computerized
physician order
entry, automated nursing documentation and computerized
patient records.
Link:
http://www.chcf.org/documents/ihealth/NursingShortageTechnology.pdf
PEDIATRIC MEDICATION SAFETY GUIDELINES
ISMP and the Pediatric Pharmacy Advocacy Group (PPAG)
have collaborated to
publish recommendations to reduce the risk of medication
errors in the
pediatric population. The guidelines are endorsed by the
Society of
Pediatric Nurses and are designed to improve medication
safety practices in
children's hospitals, general acute care hospitals with
pediatric patients,
as well as ambulatory pediatric clinics.
Link:
http://www.ismp.org/worddoc/pediatricpharmacyguidelines.doc
JCAHO SENTINEL EVENT STATISTICS
JCAHO has reviewed 1,609 sentinel events since January
1995. Of those, the
most common are patient suicide (16.7%), op/post-op
complications (12.2%),
medication errors (11.4 percent), and wrong-site surgery
(11.3%).
Link:
http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/index.htm
MEDMARX 2000 SURVEY RESULTS
The U.S. Pharmacopeia has released its second annual
MedMARx report
revealing:
+ 42% of all error originated in the administration
phase.
+ About 69% of medication errors reported reached the
patient, while 31% did
not.
+ Errors reported "most frequently" included
errors of omission, "improper"
dose or quantity and "unauthorized drugs."
+ The "top causes" cited included performance
deficit, failure to adhere to
procedure or protocol or inaccurate or omitted
transcription.
Link: http://www.usp.org/medmarx2000
CHARTBOOK EXAMINES QUALITY OF HEALTH CARE
In May the Commonwealth Fund released a new chartbook
that is a first-of-its
kind portrait of the state of health care quality in the
United States.
"Quality of Health Care in the United States: A
Chartbook" by Sheila
Leatherman, contends that preventable medical mistakes
are a serious
problem. Specifically, Leatherman cites the increases in
medication mistakes
from 1987 to 1995, in which the rates of
medication-prescribing mistakes
with the potential for adverse outcomes more than tripled
in proportion to
hospital admissions.
Link:
http://www.kaisernetwork.org/healthcast/alliance/10may02
HIMSS PATIENT SAFETY WHITE PAPER
The Healthcare Information and Management Systems Society
(HIMSS) has
released a white paper entitled "A Technological
Approach to Enhancing
Patient Safety." Authored by Kathleen Covert Kimmel,
RN and Joyce Sensmeier,
RN the white paper contends that the time has come
"for hospitals to take
stock of their technology and applications and evaluate
clinical workflow.
Technology, combined with clinical process
transformation, holds the most
promise for improvement." Specifically the authors
cite computerized
physician order entry (CPOE) and bar-coded medication
administration as two
proven, technology-supported work processes that can
reduce medical errors.
Link:http://www.himss.org/content/files/whitepapers/patient_safety.pdf
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TAKING ACTION
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RHODE ISLAND QUALITY INSTITUTE
Rhode Island Attorney General Sheldon Whitehouse has
announced the launching
of The Rhode Island Quality Institute, which will promote
safer health care,
reduced waste, and an improved health care system. The
Quality Institute is
comprised of hospitals, physicians, nurses, business
leaders, insurance
companies and governmental representatives.
Link:
http://www.riag.state.ri.us/press/Jun02/061002_RI%20Quality%20Institute%20La
unched.htm
ALABAMA ALLIANCE FOR PATIENT SAFETY
An unprecedented alliance of Alabama health care
professionals met in May
with the aim of working together to ensure that the
citizens of Alabama
receive healthcare in a safe environment.
The Alabama Alliance for Patient Safety (AAPS) is
composed of
representatives from physician groups, hospitals, state
health agencies, the
state legislature and health care quality organizations,
including Alabama
Quality Assurance Foundation (AQAF).
NEW GROUP TO FOCUS ON HEALTH I.T. STANDARDS
The National Alliance for Health Information Technology
was launched June
25th in Washington to create voluntary health care IT
standards. This new
organization is made up of health care providers,
information technology
vendors, and health and technology associations. The Alliance hopes to
improve patient safety through efforts such as applying
bar codes to
medication in accordance with the FDA's new barcode
regulations.
Some groups involved include the American Hospital
Association, Bridge
Medical, Inc., American Society of Health-System
Pharmacists, Healthcare
Information and Management Systems Society, Premier Inc.,
and VHA Inc.
Link: http://www.bridgemedical.com/news_2002_20.shtml
STAND UP FOR PATIENT SAFETY
In April the National Patient Safety Foundation (NPSF)
launched the first
nationwide campaign to achieve measurable systems change
in hospitals.
Called "Stand Up for Patient Safety," the
initiative involves 17 "founding"
hospitals from around the country that have agreed to
serve as laboratories
to address the problem of reducing preventable medical
errors at all levels
and to promote a greater understanding of what lies
behind these errors.
Link: http://www.npsf.org/html/pressrel/standup.html
INDEX OF PATIENT SAFETY COALITIONS
Patient safety organizations are constantly emerging and
evolving so Sharon
Conrow Comden and Jill Rosenthal of the National Academy for
State Health
Policy set out to profile existing organizations in May.
The result is a
very comprehensive review of patient safety initiatives
across the country.
Link:
http://12.109.133.213/Files/gnl_44_patient_safety_coalitions_for_the_web.pdf
ASHP AGENDA FOR 2002-2003
Fostering fail-safe medication use in health systems
remains a top priority
addressed by ASHP's new Leadership Agenda. Approved in
May by the Society's
Board of Directors, the 2002-2003 agenda formally
communicates ASHP's
organizational priorities and serves as a framework for
future activities.
Link:
http://www.ashp.org/public/news/releases/ShowRelease.cfm?id=2938
JCAHO SENTINEL EVENT ALERT ADVISORY GROUP
The Joint Commission on Accreditation of Healthcare
Organizations (JCAHO)
has appointed a 22-member advisory group of nurses,
physicians, pharmacists,
and other patient safety experts to help develop its
first set of National
Patient Safety Goals. The first set of goals will be
announced in July and
health care organizations will be surveyed for compliance
with the goals
beginning Jan. 1, 2003.
The six recommended 2003 National Patient Safety Goal
topics are:
∑ Patient
identification
∑ Communication
∑ High-alert
medications/potassium chloride
∑ Wrong-site
surgery
∑ Infusion
pumps
∑ Alarm
systems
The group's recommendations will be reviewed by JCAHO's
Board of
Commissioners at a July meeting.
Link: http://www.jcaho.org/
MADISON PATIENT SAFETY COLLABORATIVE
Madison's healthcare providers agree that any error in
patient care is
unacceptable. However, the work around patient safety had
always occurred on
a hospital-by hospital basis. That changed in September 2000, when
Madison's hospitals and medical groups formed a united
patient safety
organization, the Madison Patient Safety
Collaborative. The coalition
believes that patient safety is a common goal rather than
a competitive
issue and that, through cooperation, Madison's healthcare
providers will
achieve improvement goals faster and more efficiently.
Link: http://www.madisonpatientsafety.org/
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BARCODE-ENABLED POINT OF CARE (BPOC) TECHNOLOGY IN THE
NEWS
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BARCODE TECHNOLOGY USE ON THE RISE
The use of information technology among healthcare
providers to improve
patient safety and reduce medical errors is increasing
and a growing number
are turning to barcoding technology to achieve this
purpose, according to a
study released by the Healthcare Information and
Management Systems Society
(HIMSS). The
study, titled the "HIMSS 2002 Hot Topics Survey," represents
the opinions of senior managers at healthcare
organizations across the
country.
Seventy-three percent of survey respondents indicated
their organizations
were addressing the issue of patient safety and reducing
medical errors,
either through information technology implementation or
development, or
through planning discussions. When asked about the type
of systems being
implemented in their organizations to improve patient
safety and reduce
medical errors, 77% reported using barcoding technology.
The use of
barcoding was most prevalent in laboratory settings (45%)
and supply-chain
management/materials management (40%). Only 15% reported
using bar coding
technology for medication administration at the point of
care.
Link: http://www.himss.org
BPOC SYSTEM REDUCES TRANSFUSION ERRORS
The number of patients who die following a blood
transfusion is on the rise,
and many of these deaths can be traced to preventable
errors by hospital
staff, according to a three-part series in Newsday. In
its review of federal
records, Newsday found that transfusion-related deaths
increased from 53 in
1995 to 68 last year; overall, at least 440 deaths were
reported between
1995 and 2001. Many errors stem from flawed blood
collection and storage
practices but the most preventable mistakes involve
transfusion with the
wrong type of blood. Moreover, wrong-blood errors kill
more patients than
any other transfusion-related mistake.
Experts say that most wrong-blood cases involve human
error by overworked
hospital employees. Advanced computer systems and other
technological
developments could prevent errors and lead to safer blood
transfusions. Some
hospitals have implemented systems to prevent such
identification errors.
Washington, D.C.-based Georgetown University Hospital is
using handheld
computers and barcodes to track blood samples.
Experts suspect government statistics don't capture the
full scope of the
transfusion problem because many hospitals fail to report
errors. By one
estimate, as little as 5% of all transfusion-related
deaths are reported.
Link: http://www.newsday.com/
BARCODING GETS A SECOND LOOK
In April, Hospitals and Health Networks featured
"Bar Coding: The Forgotten
Technology" which stated that it has been shown to
reduce medication errors
by up to 50 percent, yet bar coding creates less buzz
than computerized
physician order entry when it comes to patient safety
technology. But as
CPOE continues to meet with financial and process change
barriers, providers
are giving bar coding a second look.
The article recognized that barcoding will not advance
until the industry
accepts common standards and manufacturers begin to
provide the barcodes on
all products.
Safety experts hope recent developments, such as a Food
and Drug
Administration proposal to require bar codes on the
packaging of all
hospital-administered drugs, and a joint effort by drug
purchasers to demand
standards, will help.
HOSPITALS ADDRESS MISIDENTIFICATION ERRORS
Hospitals across the country are beginning to acknowledge
that accidents
happen and that only by recognizing that can patients be
made safer in the
future. According to a Los Angeles Times report on April
8th, hospitals are
coming to grips with the causes of harm. To avoid
misidentification of
patients one hospital, Yale-New Haven, now makes sure
that all patients have
an ID band from the time they come through the front
door. Blood handling
has been improved by more consistent use of ID bands to
reduced mix-ups.
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CAUSE FOR CONCERN
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MINNESOTA HOSPITAL LOSES FUNDING OVER MEDICATION ERRORS
Kindred Hospital, a small long-term-care hospital in
Golden Valley, has been
plagued by medication errors. The Minneapolis Star Tribune reported that
four years ago a nurse fatally injected a patient with
the wrong pain
medication. This led to the first of 11 investigations
that revealed a
pattern of problems in patient care and hospital
management. Kindred
promised the government that it would correct and prevent
its problems but
three more patients died and 53 violations were cited
before federal
investigators dropped the hospital from the Medicare and
Medical Assistance
programs in April.
A second nursing facility owned by Kindred Healthcare,
the Lexington (Ky.)
Center for Health and Rehabilitation, lost its Medicare
and Medicaid
certification in May because of patient-safety
violations. With nearly 84%
of the home's 156 residents Medicare or Medicaid
beneficiaries, it is
doubtful that the facility will survive this sanction.
Link: http://www.startribune.com/stories/462/2228002.html
OVERDOSE DEATH OF NEW MOTHER
The Macon Telegraph reported that the Medical Center of
Central Georgia and
Central Georgia Anesthesia Services have denied any
wrongdoing in their care
of a 24-year-old mother, Shirlene Redding, who allegedly
died from an
overdose of pain medication administered while she was in
the hospital.
Redding died at The Medical Center on June 10, 2000, less
than 24 hours
after giving birth to a girl by Cesarean section. The
lawsuit alleges the
hospital; the anesthesia service and the doctors and
nurses who were present
did not properly monitor the amount of pain medication
Redding received.
Before and after the birth, Redding was allegedly given
intravenous doses of
fentanyl, an opiate-based narcotic commonly used in labor
and delivery. The
suit also alleges the nursing staff inadequately
documented the
administration of the fentanyl, failed to properly assess
Redding's vital
signs, continued to administer fentanyl despite an
adverse reaction to a
test dose and failed to discontinue the fentanyl once
Redding's breathing
and heart stopped.
Link:
http://www.macon.com/mld/telegraph/3484110.htm?template=contentModules/print
story.jsp
JURY FAULTS HOSPITAL FOR WRONG DRUG ERROR
The Dallas-Fort Worth Star-Telegram reported that a
Tarrant County jury
awarded more than $13 million to the mother of a
46-year-old man who is
incapacitated by brain damage since being treated at
Columbia Medical Center
of Las Colinas.
Columbia was ordered to pay 98 percent of the damages, and
the registered nurse involved in the suit is to pay 2
percent.
According to the suit, on Jan. 19, 2000, Scott Bush
walked into the
emergency room with a rapid heartbeat and was treated
with the incorrect
medicine, which caused his blood pressure to drop and led
to brain damage.
Link: http://www.dfw.com/mld/dfw/archives/
FAMILY SEEKS DEAL WITH FLORIDA HOSPITAL IN OVERDOSE CASE
The Olympian in June reported that the family of a
25-year-old woman who
died at Providence St. Peter Hospital in April 1999 put
its case before the
public this week as a way to pressure the hospital into
settlement
negotiations, their attorney, Matt O'Meara, said.
The family of Kristen Griffin of Tumwater has a $5
million lawsuit pending
against the hospital, claiming her April 1999 death was
the result of an
overdose of medication. Griffin went to the hospital's
emergency room with
severe stomach pain April 20, 1999. Hospital officials
performed an MRI and
determined that Griffin needed to have gallbladder
surgery. Griffin survived
a 46-minute surgery to remove her gallbladder April 22,
1999. After surgery,
plaintiffs say, Griffin was transported to the hospital's
post-anesthesia
care unit, where she was administered twice the
prescribed dose of Fentanyl,
a narcotic used to relieve pain, according to the
plaintiff's complaint.
The Nurse also hooked Griffin up to a patient-controlled
analgesic machine
containing Dilaudid, another narcotic used for pain.
Griffin had already
received Fentanyl, morphine and other pain medication.
Link:
http://www.theolympian.com/home/news/20020619/southsound/41080.shtml
SOUTH CAROLINA LOOKS AT MEDICAL ERRORS
The State Newspaper on June 17th reported that mistakes
by doctors, nurses,
pharmacies and hospital staffs kill and injure South
Carolinians each year.
The exact number of accidental deaths and injuries is
unknown and experts
say the public has no idea of just how common deadly
errors and accidents
are.
Since last fall, however, Medical University of South
Carolina has paid out
$3.8 million to compensate five families for damages from
medical errors. In
Aiken County, a jury awarded $6.9 million in the 1996
death of a nurse,
37-year-old Marshall Welch. It found Welch was given
massive doses of
narcotics following an operation. After the S.C. Court of
Appeals upheld the
verdict in 2000, the parties settled.
Some Reforms are underway. Although no statewide
initiative exists, some
hospitals and groups are taking steps to improve patient
safety. The Medical
University of South Carolina has begun a safety push,
including studying
errors and making patients more aware of safety issues.
Likewise, the S.C.
Hospital Association's patient safety committee has begun
a statewide effort
to reduce medication errors.
Link:
http://www.thestate.com/mld/thestate/news/3486688.htm
FDA BARCODING RULE MAY REDUCE UNIT-DOSE MEDICATIONS
It is possible that a FDA proposal to require barcodes on
drug labels could
have a negative effect on medication safety. The FDA
announced last year
that it would require all drug products used in
hospitals-including
single-dose packages-to carry a barcode. The rule is
intended to encourage
hospitals to implement BPOC technology. But providers
worry that drug makers
will respond by eliminating single-dose packages of many
drugs, in order to
reduce the cost of complying with the rule. The FDA estimated compliance
costs for the drug industry at $1.4 billion across 10
years.
Link: http://www.fda.gov/
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GRANTS
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CHFC & RWJF QUALITY IMPROVEMENT GRANT
CHCF and the Robert Wood Johnson Foundation are
evaluating proposals for
nearly $9 million in grants for development of
non-financial incentives to
make improving the quality of patient care more
worthwhile for medical
providers.
Link: http://www.chcf.org/topics/view.cfm?itemid=19732
AHRQ PARTNERSHIP FOR QUALITY GRANTS
The Agency for Healthcare Research and Quality (AHRQ)
invites applications
designed to accelerate the pace with which research
findings are translated
into improved quality of care and the health care
system's ability to
deliver that care.
In Phase 1 of this grant process, up to 10 projects will
be funded with up to $100,000 each.
Link:
http://grants.nih.gov/grants/guide/rfa-files/RFA-HS-02-010.html
HHS FUNDS RURAL HOSPITALS TO REDUCE ERROR
The Health Resources and Services Administration (HRSA)
announced that
applications are being accepted for grants to small rural
hospitals to help
them do any or all of the following:
1. Pay for costs related to the implementation of
prospective payment
systems (PPS),
2. Comply with provisions of the Health Insurance
Portability and
Accountability Act (HIPAA) of 1996, and
3. Reduce medical errors and support quality improvement.
Link: www.hrsa.gov/
REWARDING RESULTS
A national initiative of The Robert Wood Johnson
Foundation (RWJF) and other
funding and technical assistance partners called the
"Rewarding Results"
initiative is intended to develop, evaluate, and diffuse
innovations in
systems of provider payments and non-financial incentives
that encourage and
reward high-quality care.
Link:
http://grants.nih.gov/grants/guide/rfa-files/RFA-HS-02-006.html.
THREE HOSPITALS GET $5.7 MILLION FOR PATIENT SAFETY I.T.
SYSTEMS
Three U.S. healthcare facilities have received nearly $2
million each from
the Robert Wood Johnson Foundation to bolster e-health
initiatives aimed at
enhancing patient safety and streamlining practice
management. Tallahassee
Memorial Healthcare is redesigning and implementing CPOE,
automated
dispensing, and barcoding. South Carolina's McLeod
Regional Medical Center
plans a personal digital assistant-based e-prescribing
network for doctors.
And the Minnesota-based HealthPartners group has proposed
a Web-enabled
electronic medical record system by 2004.
******************************************************
EVENTS
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LEADING THE PATIENT SAFETY MISSION
September 3-5, 2002 in Newport, Rhode Island
The American Society of Law, Medicine & Ethics and
the Risk Management
Foundation of the Harvard Medical Institutions announce
their first national
patient safety forum.
Link: http://www.aslme.org/conferences.
NAHQ's ANNUAL EDUCATIONAL CONFERENCE
Sept 7-9, 2003 - Marriott's Desert Ridge Resort &
Spa, Scottsdale, AZ
The Conference theme is "On Par With Quality"
Link: http://www.nahq.org/conference/
ANNUAL DISEASE MANAGEMENT CONGRESS
Sept. 18-20, 2002, Sheraton Hotel & Towers, Chicago,
IL
The 7th Annual Disease Management Congress will explore
quality themes for
employers, providers, health plans, government,
pharmaceutical companies and
vendors.
Link: http://www.nmhcc.org/dmc
THE eHEALTH DEVELOPERS' SUMMIT 2002
Nov. 6-8, 2002 Tempe, AZ
The eHealth Developers' Summit seeks to catalyze the
sustainable
development, adoption, and dissemination of effective
eHealth tools by
leveraging the collective expertise and vision of the
most respected eHealth
developers in the world.
Link: http://www.ehealthinstitute.org/summit/index.cfm
NPSF ANNENBERG CONFERENCE V
March 14-17, 2003, Washington, DC
Patient Safety theme to be announced
Link: http://www.npsf.org/
WORKING WITH SURVIVORS OF MEDICAL ERROR
April 7, 2003, VA Medical Center, Northport, Long Island
NY
This program will provide both appropriate background
information and
practical tips to help health care systems and support
staff meet the needs
of victims and survivors of medical errors and
substandard health care.
Sponsored by The Long Island Patient Safety Council, The
Northport VA
Medical Center, and PULSE of NY.
Link: www.PULSEofNY.COM
Visit our complete listing of patient safety related
events at
http://www.bridgemedical.com/.
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BRIDGE NEWS
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BRIDGE MEDICAL NAMED UP& COMER BY HEALTHCARE
INFORMATICS
In June, Bridge Medical was chosen by Healthcare
Informatics to be included
in this year's Up & Comers List. This year's awardees offer some of the
hottest solutions on the market, including biometrics,
data security,
enterprise wide electronic clinical solutions, patient
safety and bar-coding
products, Internet and messaging security solutions,
physician e-procurement
and point-of-care decision support tools. The companies
highlighted are
distinguishing themselves through focused and pragmatic
technical solutions,
smart acquisitions and partnerships, and most of all,
clear strategies
geared to carry them deep into healthcare's future.
Link: http://www.bridgemedical.com/media_cov_6_02.shtml
NEW BOOK DEMONSTRATES TECHNOLOGY'S IMPACT ON PATIENT
SAFETY
In a new book released by the Healthcare Information and
Management Systems
Society (HIMSS), the proper use of information technology
is presented as
the key to preventing many of the common medical errors.
Entitled The Impact
of Information Technology on Patient Safety, the book is
written by "a
veritable 'who's who' of patient safety experts"
said HIMSS President/CEO H.
Stephen Lieber.
"All of the authors are advocates of technology's
power to transform the
current hospital environment into one where patient
safety is a given not a
goal," said editor Russell F. Lewis, an executive at
Bridge Medical.
"Spiraling healthcare costs, nursing shortages,
regulatory and legislative
initiatives, as well as the rise of consumerism in
healthcare make improving
patient safety not only the right thing to do, but an essential
business
strategy."
Link: http://www.himss.org/ASP/books_media_list.asp.
MOUNT CARMEL HEALTH SYSTEM TO INSTALL MEDPOINT
Ohio's first healthcare organization to contract for
patient safety
technology from Bridge Medical, Mount Carmel-a
three-hospital health system
based in Columbus-will implement Bridge's MedPoint(tm)
and InfoPoint(tm)
software systems later this summer.
"Once MedPoint is fully deployed," said Mount
Carmel SVP/CIO Cynthia L.
Sheets, "we can begin collecting valuable
prospective and retrospective
patient and medication-use data. InfoPoint allows us to
analyze this data
and extract important information for use in patient
care. Experts have
found that the best-managed hospitals make extensive use
of technology. Our
new partnership with Bridge illustrates this
perfectly."
Link: http://www.bridgemedical.com/news_2002_18.shtml
EISENHOWER MEMORIAL FIRST IN CALIFORNIA TO IMPLEMENT
MEDPOINT
In May, Eisenhower Medical Center (EMC) President and CEO
G. Aubrey Serfling
announced that Eisenhower is the first California
healthcare provider to
embark on a program to use barcode technology to
intercept both medication
and blood transfusion errors at the hospital bedside. EMC
has contracted to
begin deploying Bridge Medical's MedPoint system at its
261-bed Eisenhower
Memorial Hospital.
Link: http://www.bridgemedical.com/news_2002_15.shtml
WASHINGTON HOSPITALS EMBRACE BRIDGE TECHNOLOGY FOR
PATIENT SAFETY
Since 1999, Sacred Heart has been testing a patient
safety system from
Bridge Medical called MedPoint. The barcode-enabled
point-of-care (BPOC)
software system uses expert databases and wireless
communications to prevent
medication errors. The system also helps hospitals
prevent potential errors
involving blood transfusions or lab specimen collection.
In June Sacred Heart announced a new contract to deploy
the now thoroughly
tested and proven software throughout Sacred Heart and
four other Providence
health system facilities.
Link: http://www.bridgemedical.com/news_2002_19.shtml
ST. MARYS RECOGNIZED FOR EXCELLENCE IN NURSING
Bridge customer St. Marys Hospital Medical Center,
Madison, WI has received
Magnet Recognition for Nursing Excellence, the highest
national honor
bestowed for nursing, given by the American Nurses
Credentialing Center.
Only four other hospitals in the Midwest share this
status- 48 hospitals in
the nation.
To receive the award, a hospital must demonstrate that it
provides quality
patient care through nursing excellence. St. Marys also
had to host a
three-day intensive visit by the program reviewers. St. Marys now serves as
a nationwide model for other nursing organizations.
Link: http://www.bridgemedical.com/st_marys_award.shtml
ST. MARYS RECEIVES GRANT FOR BARCODING INITIATIVE
Thanks to its participation in the Madison Patient Safety
Collaborative, St.
Marys recently received a grant from "The
Alliance" in Madison to help
support its barcoding patient safety initiative. A member
of The Leapfrog
Group, the Alliance (Employer Health Care Alliance
Cooperative) is an
employer-owned-and-directed cooperative that strives to
manage healthcare
costs while improving the health of the community.
Link: http://www.bridgemedical.com/st_marys.shtml
BRIDGE & MIAMI CHILDREN'S FEATURED IN NURSING
SPECTRUM MAGAZINE
Bridge customer, Miami Children's Hospital was recently
featured in an
article in Florida's Nursing Spectrum Magazine. The Miami Children's
project manager, Cheryl Topps, authored the column
describing Miami
Children's endeavor with Bridge technology saying,
"The immediate goal of
the project is to enhance delivery of care and prevent
potential errors. But
it's also an effort to put together a user-friendly
system for staff nurses.
The nursing shortage presents big challenges for all
regional hospitals.
Miami Children's also takes the commitment to patient
safety seriously. That
commitment to patients and staff prompted the interest in
a bar code system
that would reduce chances of medication error - and
reassure bedside nurses
that the hospital is providing the support they need to
deliver top-notch
care."
Link:
http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=6881
WEST VIRGINIA HOSPITAL REPORTS BPOC SYSTEM RESULTS
Weirton Medical Center, Weirton, W.V., reduced the
potential for medication
errors and lightened the paperwork burden for nurses by
installing a bar
code point of care (BPOC) system for drug verification,
according to a case
presented in the May issue of Health Management
Technology. Weirton chose
the Bridge MedPoint BPOC system. Weirton installed BPOC devices at each
of
the 30 beds in its intermediate care between March and
May of 2001.
A comparison of medical error reports before and after
implementation of the
BPOC system suggests that the system has helped nurses
avoid medication
errors. Hospital staff filed 16 medication incident
reports in June 2000,
before the system was in place. By comparison, they filed
only six incident
reports in June 2001, following the system's launch. A
retrospective
analysis of 89 errors that occurred before the installation
of the BPOC
system shows that the system would have prevented errors
in 46% of the
cases. After seven months of testing, Weirton adopted the
system throughout
the hospital.
Link: http://www.healthmgttech.com/
####################################################
A BRIDGE MOMENT
Submitted by Sacred Heart Medical Center.
####################################################
We often cite the ability of MedPoint to free nurses from
administrative
tasks but one of our pharmacists at Sacred Heart Medical
Center reported a
terrific example of the positive impact on pharmacy in
our sites. The 6th
floor clinical pharmacist at Sacred Heart said that he is
no longer spending
a hour each morning correcting order entry from the
previous day (daily MAR
corrections) and is using that time to perform other
clinical duties. He
also reported accessing the MedPoint device in a
patient's room to get the
exact time of administration and next dose due time for a
Vancomycin, a time
sensitive antibiotic, for monitoring and adjusting the
dosage calculation.
******************************************************
CASE STUDY OF MEDPOINT ERROR PREVENTION
******************************************************
In its May 1,2002 ISMP Medication Safety Alert! the
Institute for Safe
Medication Practices (ISMP) illustrates the value of
verifying "missing
doses" before dispensing them to patient care units
in the following error
report.
Postoperatively, a patient who had undergone a leg
amputation was prescribed
AVANDIA 8 mg po daily. The pharmacy profiled the order
and sent one dose to
the unit. However, because of poor penmanship, a nurse
transcribed the order
on the medication administration record as COUMADIN
(warfarin) 8 mg daily.
When the warfarin dose was due, 5 pm, a nurse called the
pharmacy for the
"missing medication." Unfortunately, the
evening pharmacist was busy at the
time, so he sent a "one time dose" of warfarin
8 mg to the floor without
checking the patient's profile or verifying the order.
The next evening, the
nurse called the same pharmacist for the warfarin dose
and he sent it again
without verifying the order. On the third night, when the
nurse called
again, the busy pharmacist took the time to add the
warfarin order to the
patient's profile as a daily dose, but this was done
without an actual order
for verification. The error continued for another two
days until a physician
discovered it on the pharmacy computer-generated summary
of currently
prescribed medications in the patient's chart.
After receiving fresh frozen plasma, vitamin K, and
appropriate antidiabetic
therapy, the patient recovered with no permanent harm.
IF MEDPOINT HAD BEEN PRESENT...
One key point here is that the NURSE transcribed the
order as "COUMADIN",
but the pharmacist entered the order as
"AVANDIA". If they had used
MedPoint, the nurse would have seen the pharmacist's
interpretation of the
order as soon as it was entered because MedPoint gives
nurses immediate
visibility to orders in the pharmacy system. If the nurse was confused, she
could have flagged the order with a "needs
clarification" marker until she
conferred with the pharmacist. Catching this kind of error up-front is
critical to stopping medication errors from perpetuating
for several days.
Without a doubt, there were several process steps that
failed allowing this
error to go on for so long, but MedPoint's order
confirmation feature would
have helped to eliminate the error before it reached the
patient.
******************************************************
ACKNOWLEDGEMENTS:
******************************************************
Bridge Medical wishes to express our gratitude for the
continued work of the
National Patient Safety foundation, the California
HealthCare Foundation,
the American Society of Health-System Pharmacists, the
Advisory Board,
Modern Healthcare, the Institute for Safe Medication
Practices and the
American Hospital Association in delivering invaluable
information on
patient safety.
Without these organizations' contributions, the Point of
Care would not be possible.
**************************************************************************
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 Bridge Medical.