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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.

 

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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.