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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 3 - Fall 2002
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CONTENTS
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SPECIAL DELIVERY
LEGISLATIVE & REGULATORY
RESEARCH
TAKING ACTION
BPOC IN THE NEWS
CAUSE FOR CONCERN
GRANTS
EVENTS
BRIDGE NEWS
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SPECIAL DELIVERY
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NEW WHITE PAPER REVIEWS EVIDENCE OF BARCODING EFFICACY
Bridge's new white paper reviews evidence of "The
Effect of Barcode-enabled
Point of Care Technology on Patient Safety."
Notes Institute for Safe Medication Practices President
Michael R. Cohen,
RPh, MS, DSc, FASHP, in the foreword: "As
stakeholders in the quality
improvement of this nation's healthcare, we must
recognize the vulnerability
of the patient in all of us. When a practice or
technology exists that is
proven to reduce error, it is our shared responsibility
to communicate its
efficacy. A technology has begun to take center stage
demonstrating
impressive results and demanding our attention. Barcode
enabled
point-of-care (BPOC) systems provide a safeguard against
error at the most
vulnerable stage in the medication use process-during
administration.
Peer-reviewed studies validating BPOC technology
efficacy, industry movement
to establish a healthcare barcoding standard, and the
announcement of a
future FDA ruling mandating manufacturer-applied barcodes
testify to BPOC
systems' coming of age. Its effective use can save lives
and dollars while
increasing overall staff efficiency."
In addition to describing how BPOC systems can be used to
prevent medication
administration errors in the hospital setting, the Bridge
literature review
examines the efficacy of barcoding in preventing blood
transfusion and
laboratory specimen collection errors.
A free copy will be available by November 1, 2002 at:
http://www.bridgemedical.com/pdf/whitepaper_barcode.pdf .
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LEGISLATIVE & REGULATORY
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JCAHO UNVEILS 2003 NATIONAL PATIENT SAFETY GOALS
The Joint Commission's Board of Commissioners has
approved for
implementation effective January 1, 2003 a set of six
National Patient
Safety Goals representing 11 recommendations for
improving the safety of
patient care in health care organizations. Among the
Joint Commission
recommendations is:
Improve the accuracy of patient identification.
a) Use at least two patient identifiers (neither to be
the patient's room
number) whenever taking blood samples or administering
medications or blood
products.
b) Prior to the start of any surgical or invasive
procedure, conduct a final
verification process, such as a "time out," to
confirm the correct patient,
procedure and site, using active not passive
communication techniques.
For many hospitals, barcode enabled point of care (BPOC)
verification
systems will serve an important role in providing a
reliable form of patient
identification. Beginning with surveys after Jan. 1,
2003, organizations
should expect this goal to become a routine part of the
survey process.
Grading is on a pass/fail basis. Hospitals either fulfill
all 11 safety
guidelines, or they will receive a type 1 recommendation.
Link:
http://www.jcaho.org/About+Us/News+Letters/JCAHOnline/JO_8_02.htm - 1
JCAHO WHITE PAPER: HEALTH CARE AT THE CROSSROADS
This report, "Strategies for Addressing the Evolving
Nursing Strategies for
Addressing the Evolving Nursing Crisis" offers
recommendations for
alleviating the nursing shortage and its impact on
healthcare quality. These
recommendations include:
- Minimize
the paperwork and administrative burden that takes away from
patient care-74% of nurses surveyed said they would stay
at their job if
such changes were made.
- Adopt information, ergonomic and other technologies
designed to improve
workflow and reduce risk of error and injury.
According to the report, "... technologies, such as
bar coding and scanning,
and robotics can reduce nursing time spent on supply
management and
documentation, and facilitate safe and efficient
medication administration,
even in the face of shortages of pharmacy and ancillary
personnel."
Link:
http://www.jcaho.org/News+Room/news+release+archives/health+care+at+the+cros
sroads.pdf
IT COALITION SUPPORTS SENATE BILL 842
In July, the I.T. Coalition in Washington DC sent the
following letter to
the hill offering industry wide support for Senate bill
842-Medication
Errors Reduction Act of 2001. More than two dozen member
organizations
signed on to support this message:
Dear Senator:
On behalf of the undersigned organizations, we would like
to express our
continued support for the Medication Errors Reduction Act
of 2001 (S. 824),
and to urge that the funding necessary to improve patient
safety be included
in Medicare legislation currently under consideration.
Medication errors and other preventable adverse events
remain a significant
concern for providers and patients alike. S. 824 would
help hospitals and
nursing homes offset the prohibitively high costs of
implementing and
administering clinical healthcare informatics systems
designed to improve
patient safety and reduce error.
By focusing on pro-active, strategic solutions, this
legislation would
hasten sustainable healthcare quality improvement. The stipulated funding
would effectively remove the most significant obstacle
retarding hospitals'
adoption of comprehensive medical error reduction
systems-cost. Grants
available under S. 824 would help hospitals and nursing
homes finance the
acquisition, implementation, upgrade, education and
training costs of new
patient safety and error-reduction technology.
In this way, the efforts of early adopters-pioneers, if
you will-of new
patient safety technologies may be simultaneously
rewarded and facilitated.
Furthermore, these grants would place new technologies
within the reach of
hospitals and nursing homes-and most critically, their
patients-throughout
the country, including those in rural and/or
traditionally under-served
areas.
Research studies in the patient safety arena have
indicated that federal
cost-sharing of this kind could render achievable the
goal of integrating
medication error reduction systems in 25 percent of
hospitals and nursing
homes participating in Medicare over the next decade.
Again, we would strongly urge the inclusion of funding in
pending Medicare
legislation to facilitate the reduction of medication
errors and improve the
safety of America's healthcare system.
FEDERAL PATIENT SAFETY LEGISLATION PROGRESSES
Speakers testified before the House Ways and Means Health
Subcommittee on
September 10 in support of H.R. 4889, legislation that
would establish
voluntary standards for reporting medical errors to newly
created Patient
Safety Organizations and would expand the activities of
AHRQ's Center for
Quality Improvement and Patient Safety to collect patient
safety data from
the new organizations. The full Ways and Means Committee passed H.R. 4889
on September 18, and the full House Energy and Commerce
Committee passed a
similar bill, H.R. 5478, on September 26. The two
committees will try to
reconcile the differing provisions and bring a
consolidated bill to the
House floor this week.
In addition, Sen. Edward Kennedy (D-MA), chairman of the
Senate Health,
Education, Labor, and Pensions Committee, has circulated
a draft bill that
includes provisions from both House bills. In addition to
protections for
error reporting, Kennedy's bill would provide grants for
hospitals "to
develop, install, or train personnel in the use of"
CPOE systems. The
legislation would also fund a study to gauge CPOE's
efficacy and cost
effectiveness.
Testimony Available at:
http://waysandmeans.house.gov/health/107cong/hl-17wit.htm.
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RESEARCH
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MEDICATION ERRORS OBSERVED IN 36 HEALTH CARE FACILITIES
Kenneth N. Barker, PhD; Elizabeth A. Flynn, PhD; Ginette
A. Pepper, PhD;
David W. Bates, MD, MSc; Robert L. Mikeal, PhD. Arch
Intern Med.
2002;162:1897-1903
This study's objective was to identify the prevalence of
medication errors
(doses administered differently than ordered) among a
stratified random
sample of 36 institutions including hospitals, and
skilled nursing
facilities in Georgia and Colorado.
To ascertain the incidence, researchers observed
medication doses given (or
omitted) during at least 1 medication pass during a 1- to
4-day period by
nurses on high medication-volume nursing units.
In the 36 institutions, 19% of the doses were in error.
The most frequent
errors by category were wrong time (43%), omission (30%),
wrong dose (17%)
and unauthorized drug (4%). Seven percent of the errors
were judged
potential adverse drug events.
The researchers concluded that medication errors were
common (nearly 1 of
every 5 doses in the typical hospital and skilled nursing
facility). The
percentage of errors rated potentially harmful equates to
more than 40 per
day in a typical 300-patient facility leading to the
conclusion that
defective medication administration systems are
widespread.
INTEGRATED MEDICATION DELIVERY SYSTEMS MORE EFFECTIVE IN
REDUCING ERRORS
Journal of the American Medical Informatics Association,
September 11, 2002
Researchers from Purdue University and the University of
Indiana used
computer simulation technology to model the impact on
medical error rates of
five different IT strategies: computer-based dosing
information at the point
of care; CPOE; an automated pharmacy dispensing system; a
barcoding system,
and an integrated system that encompassed all of the
other strategies. They
found that a "comprehensive" medication
delivery system, including a
combination technologies could reduce medical errors by
as much as 26%-more
than any other strategy on its own-because it addresses
potential medical
errors during prescription, transcription, dispensing and
administration,
the study found. By comparison, CPOE alone would reduce
medical errors by
only about 4%, according to the study.
Moreover, researchers estimated an annual decline in
patient hospital stays
resulting from medical errors at more than 1200 days and
a $1.4 million
reduction in related costs each year.
The article may be purchased by non-subscribers at
http://www.jamia.org/.
STUDY LOOKS AT CHALLENGES OF ONE BPOC SYSTEM
Emily Patterson, Richard Cook and Marta Render, Journal
of the American
Medical Informatics Association
This investigation of the Veterans Health
Administration's Bar Code
Medication Administration (BCMA) barcoding system asserts
that new paths to
ADEs may be a possible side effect. This assertion is
based on the
observations of one investigator evaluating nurses at one
VAMC before and
after the BCMA system was installed. These observations
were made:
1. Nurses
were confused by automated removal of meds from BCMA.
2. There
was degraded coordination between nurses and physicians.
3. Nurses
dropping activities to reduce workload during busy periods.
4. Nurses
were worried that BCMA too accurately documents medication
administration time causing them to be stressed and
possibly neglectful of
more pressing patient needs.
The researchers concluded that none of these side effects
are inherent to
BPOC technology and that they may be addressed by design
revisions,
modifications of hospital policies, and better training.
The article may be purchased by non-subscribers at
http://www.jamia.org/.
JCAHO RELEASES UPDATED SENTINEL EVENT STATISTICS
Patient suicide remains the most frequently reported
sentinel event
according to new statistics released by JCAHO. Patient
suicides (16.5% of
the total sentinel events) were followed by operative or
postoperative
complications (12.3%), medication error (11.4%), and
wrong-site surgery
(11.3%). Patient death remains the most common sentinel
event outcome at
75%.
Link:
http://www.jcaho.org/accredited+organizations/hospitals/sentinel+events/sent
inel+event+statistics.htm
CASUALTIES TIED TO GAPS IN NURSING
Boston Globe, by Anne Barnard 8/7/2002
Inadequate nurse staffing contributes to nearly a quarter
of hospital
incidents that kill or injure patients according to a
report provided by
JCAHO. The group called on the federal government and the
healthcare
industry to act more aggressively on the growing shortage
of registered
nurses.
The report suggests that the shortage of nurses is a
factor in tens of
thousands of deaths annually from causes ranging from
medication errors to
patient falls and hospital-acquired infections.
The commission based its findings on the hospitals'
assessments of
unexpected adverse outcomes that either killed patients
or caused them
serious physical or psychological harm. Of the 1,609
adverse events that
hospital officials voluntarily reported to the commission
between January
1996 and March 2002, 24 percent took place in part
because hospitals had an
insufficient number of registered nurses on the job,
according to hospital
officials.
Nurse staffing levels were deemed a contributing factor
in 25% of
transfusion incidents and 19% of medication errors. The
commission's figures
may understate the effect of the nursing shortage
medication errors, because
these errors are often underreported and because
hospitals may blame some of
them on miscommunication or insufficient training that
could also be related
to staffing levels.
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TAKING ACTION
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FDA WEIGHS MANDATORY BARCODE RULE
In the biggest news to hit the medication safety front in
years, the FDA
held a public hearing last July to consider establishing
a mandatory
medication barcoding rule. The Wall Street Journal
reported that hospital
groups and patient safety advocates urged the FDA to
"speed up efforts" to
develop and require a standardized barcode system for all
pharmaceuticals,
but drug industry representatives raised questions about
the time and
expense involved in putting such a system in place.
(Landro, July 29, 2002).
In the wake of the testimony, virtually every major U.S.
news organization
covered the story, including The New York Times. And
immediately following
the hearing, virtually every major healthcare
organization endorsed the
potential rule, including HIMSS, the American Hospital
Association, the
American Medical Association, the National Alliance for
Health Information
Technology, the American Society of Health-System
Pharmacists, the
Healthcare Distribution Management Association, and the
Patient Safety
Officer Society.
Additionally, barcoding advocates such as Mark
Neuenschwander-whom the FDA
invited to testify-maintain that barcoding can minimize
errors related to
drug dispensing and administration through the
utilization of unique
machine-readable symbols on each immediate drug package.
Neuenschwander
advocates use of a scanner to compare the barcode on a
drug product to a
specific patient's drug regimen, so nurses can easily
verify, at the point
of care, that the patient is receiving the right drug, at
the right dose, at
the right time.
While drug companies generally support barcoding, they
are "reluctant" to
invest in new packaging until the FDA requires such a
system and hospitals
have adopted the technology needed to scan barcodes. Two
pharmaceutical
companies have jumped out ahead of the pack in expanding
their barcode
packaging efforts. Abbott Laboratories intends to affix
unit-of-use barcodes
to all its hospital injectable pharmaceuticals and IV
solutions product
lines by early 2003 using a special reduced size
symbology barcoding method.
The company said it has already barcoded about 45% of its
more than 1,000
injectable pharmaceuticals and IV solutions products, and
projects it will
have 70% of these products barcoded by the end of the
year. Baxter
International Inc. is focusing on "premixed"
drugs, which are packaged ready
for use and do not require additional mixing by a
hospital pharmacist.
Not all factions of the healthcare industry are thrilled
by the FDA's intent
to rule. Opponents point out that putting barcodes on
medications will
increase healthcare costs, take years to implement and
may not prevent
deadly mix-ups.
HOSPITALS FIND TECHNOLOGY AIDS CARE, CUTS COSTS
Denver Post, Sunday, September 08, 2002, By Andy Vuong
Many Denver area hospitals are implementing new
technologies that can
minimize mistakes, lower costs and give patients easier
access to their
medical records reports The Denver Post. Better
technology also improves
safety.
Certain areas of Aurora Medical Center and Rose Medical
Center have a
program called Electronic Medical Administration Record
System that aims to
eliminate medication errors. The system involves putting
barcodes on patient
ID bracelets to ensure they are given the correct
medications according to
the Post. Six-hospital HealthOne-Denver's largest
system-hopes to roll-out
the system throughout both Aurora and Rose by end of
2003, and at other
hospitals in two to three years, said Roland Sawyer,
director of information
systems for HealthOne parent HCA.
"We believe that this is going to have a profound
impact on reducing
medication errors," he said.
University Hospital is piloting several programs,
including one that could
create a so-called "paperless" environment.
Link:
http://www.denverpost.com/Stories/0,1413,36%257E33%257E843453,00.html?search
=filter (expires after 60 days).
SUTTER HEALTH TO INVEST IN INNOVATIVE PATIENT SAFETY
TECHNOLOGY
August 13, 2002
As part of an ongoing commitment to improving quality
care and patient
safety, the not-for-profit Sutter Health network of
hospitals and physicians
announced a $50 million investment in new advanced
technology that promises
fundamental changes in hospital ICU care and bedside
medication delivery.
As part of this initiative, all 26 hospitals within the
Sutter network will
begin applying advanced technology to administering
patient medications at
the bedside. A computer barcode on each patient's
identification bracelet
will be used to match and monitor the medication ordered
by the doctor.
Before administering medications, nurses and other
caregivers will scan a
barcode imprinted on the patient's armband, and on the
medication, using a
hand-held device. A bedside computer will then
"read" these barcodes into a
software application that uses expert databases to
provide patient-specific
information.
Sutter has selected MedPoint,(tm)-the barcode-enabled
point-of-care (BPOC)
patient safety software system pioneered by Bridge
Medical-to provide this
advanced safety net for patients and nurses.
Link:
http://www.sutterhealth.com/about/news/news_hsp-future.html
HIGH-TECH ALEGENT STRIVES TO GO PAPERLESS
Excerpts from Omaha World-Herald, Thursday, September 5,
2002
Alegent Health is investing $150 million in medical
technology to reduce
paperwork for doctors and nurses, shorten tedious waits
for patients and
reduce dangerous medication errors. Lakeside Hospital in
West Omaha will
showcase these technologies as a "paperless
hospital" when it opens in 2004.
A centerpiece of Alegent's investment will be a digital
record-keeping
system that will allow doctors to instantly call up those
records on
wireless, hand-held devices. The system will handle all
hospital
prescriptions, reducing the chance of medication errors.
Doctors will enter
prescription orders electronically and nurses will be
able to scan barcodes
on the medications before administering them to patients.
A database also
will double-check the prescriptions with medical records
to make sure there
is no patient allergy or compatibility issue with another
medication the
patient is receiving.
HOSPITAL PUTS BARCODES UP IN ARMBANDS
Palm Beach Post Staff Writer, Monday, July 15, 2002 By
Susan T. Port
By October, every patient admitted to St. Lucie Medical
Center will have a
barcode on his or her armband, reports The Palm Beach
Post. The Port St.
Lucie hospital started testing a technology in July to
reduce medication
errors by ensuring that every patient receives the right
drug at the right
time. The HCA-operated hospital is introducing the
technology slowly to give
staff time to learn how to use it.
Link:
http://finaledition.pbpost.com/cgi-bin/display.cgi?id=3da4b0992c2021Mpqaweb1
P11013&doc=results.html (Registration required)
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BPOC IN THE NEWS
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WALL STREET JOURNAL EXPLORES BPOC
The Wall Street Journal drew attention to studies showing
that barcoding
systems used to scan codes on nurse's ID badges,
patients' wristbands and
drug packaging can reduce medication errors by 50% to
75%. According to The
Journal, about 10% of U.S. hospitals have already
implemented the technology
and an FDA barcode standard for medications will expedite
the adoption of
BPOC technology.
Many hospital advocacy groups believe barcoding is a
relatively inexpensive
technology that they can implement immediately, the Wall
Street Journal
reports. HCA, for example, will implement barcoding
systems at all of its
186 U.S. hospitals by 2005. Moreover, supporters say,
physicians' reluctance
to adapt to computer systems may hamper CPOE
implementation, while
pharmacists are already accustomed to computer technology
and are more
likely to embrace barcoding systems. Pharmaceutical
companies also support
barcoding, and many manufacturers, including Abbott
Laboratories, have
already begun delivering bar-coded drugs to hospitals.
CALIFORNIA HEALTHCARE FOUNDATION SERIES ON BARCODING BY
JIM RUSK
WHAT WILL AN FDA REGULATION MEAN FOR HEALTH CARE
PROVIDERS?
iHealthBeat August 8, 2002
As part of their ongoing effort to inform the healthcare
market of quality
improvement opportunities, the California HealthCare
Foundation published a
series of articles exploring barcode-enabled point of
care technology.
Author Jim Rusk began by reporting the FDA intent to
requiring barcodes on
the packages of human drugs and biologic products. The
intent to rule leads
some hospitals to believe that the FDA could require
barcode scanning for
medication verification. But according to Jerry Phillips,
acting director of
the FDA's Division of Medication Errors and Technical
Support that is not
possible.
The FDA can't require hospitals to barcode label drugs
nor can it mandate
the use of BPOC systems at the point of care. Therefore,
hospitals can be
assured that they will not have to shoulder the expense
of applying barcodes
to their medications. Instead, the FDA hope is that, if
it requires barcodes
on drug packaging, hospitals will use BPOC systems to
enhance patient
safety, reported Rusk.
What the FDA can do is require barcodes on the labels of
all drugs, whether
packaged by manufacturers or repackaged by distributors,
Phillips said. That
would help those hospitals that choose to use barcodes to
dispense or verify
medications. Many, like pharmacy automation consultant
Mark Neuenschwander
believe a regulation is necessary to advance BPOC
technology use.
Neuenschwander contends that barcoding will minimize the
potential for error
in drug dispensing and administration so long as the
packages received from
the manufacturer are consistently barcoded. That allows
the use of automated
equipment by the hospital pharmacy or distributor to
repackage and relabel
the drug as needed, with a very high rate of accuracy.
The FDA still has many issues to work out before issuing
a proposed rule for
public comment.
Namely, the administration is questioning which medical
products should carry a bar code? What information should
the barcode
contain? Where should barcodes be placed? Should the FDA
mandate a
particular bar code symbology?
Link: http://www.bridgemedical.com/patient_fda5.shtml
Q&A ON BAR CODING WITH JOHN GROTTING, CEO, BRIDGE
MEDICAL
iHealthbeat August 12, 2002 and August 14, 2002
Jim Rusk conducted a two-part interview with John
Grotting, CEO of Bridge
Medical, a provider of patient safety software that uses
barcode scanning to
verify correct administration of drugs and biologics at
the hospital
bedside.
In part one, Mr. Grotting discussed the practical
considerations that health
care providers must address in order to use bar coding to
prevent medication
errors at the point of care, and how this technology will
develop across the
next few years.
Link:
http://www.bridgemedical.com/media_cov_8_12_02.shtml
In part two of the interview, Grotting discussed the
potential impact of an
FDA regulation that could require bar codes on drug
packages; how
organizations like the Leapfrog Group influence use of
patient safety
technologies; and what will ultimately drive adoption of
bar coding in
health care.
Link:
http://www.bridgemedical.com/media_cov_8_14_02_2.shtml
IMPLEMENTING BAR CODE TECHNOLOGY IN THE HOSPITAL
iHealthbeat August 20, 2002
Author Jim Rusk reported on Sacred Heart Medical Center
in Spokane, Wash.,
which has been testing a barcode-enabled point-of-care
system for
approximately 18 months in two nursing units, with a
total of about 72 beds.
The system, made by software provider Bridge Medical, is
designed to prevent
medication errors, using barcode scanning, expert rules
and real-time alerts
to ensure proper medication administration. Sacred Heart
so far has trained
about 350 nurses on the system and currently administers
about 31,000
medication doses per month in the nursing units where the
system is used.
Providence Services of Eastern Washington, the parent
organization of Sacred
Heart, decided in June to implement the Bridge system
throughout the 623-bed
Sacred Heart and its other five hospitals. Officials hope
to finish
implementation at Sacred Heart by the end of the year and
to install the
system at the remaining hospitals in 2003.
Rusk interviewed Fred Galusha, CIO of Inland Northwest
Health Services, on
Sacred Heart's experience with BPOC technology. The two-part interview is
available at:
http://www.ihealthbeat.org/members/basecontent.asp?oldcoll=&program=1&conten
tid=23655&collectionid=542 (registration required)
ADVANCE FOR MEDICAL LABORATORY PROFESSIONALS FEATURES
BPOC AND BRIDGE
MEDICAL
Aller, Raymond. Patient ID Missing in Action? Advance
Vol. 11, Issue 9, Page
50
Dr. Raymond Aller presents a discussion of laboratory
specimen
identification and the safety factors associated with
ensuring positive
identification. In this article Dr Aller asserts
that "nothing can be more
basic than ensuring that the caregiver is performing the
right procedure on
the right person." Yet, misidentification is a
systemic problem throughout
the health system. Misidentification is a particular risk
in transfusion and
specimen processing since there are multiple avenues to
error. The patient
can be misidentified, the specimen can be matched to the
wrong Patient, the
results of a test can be annotated to the wrong patient
record and/or the
wrong type of blood can be transfused.
Dr. Aller emphasized that the effects of
misidentification in the laboratory
and transfusion processes can include not only these
errors, but
misdiagnosis, missed diagnosis and serious medication
errors. To solve this
problem, the article identifies point-of-care ID systems
unequivocally
matching the patient with who he or she really is. While
Dr. Aller
anticipates that several technologies will emerge to
provide reliability in
positive patient ID, barcoding can be an immediate and
effective part of a
solution to misidentification errors.
In conclusion, Dr. Aller quotes noted transfusion
researcher Dr. Kathleen
Sazama,
"Errors in patient ID are correctable today. This is a resource
issue. Systems exist or are well along in development
that would provide us
with the means by which we could objectively identify
every patient for
every procedure. We simply haven't done it."
BARCODING PATIENTS
Newsweek Web Exclusive, Aug. 16, 2002
In August, Newsweek asked what is being done to fix the
medication use
system in the wake of the Institute of Medicine report
three years ago?
The magazine reported progress at the Veterans
Administration Medical Center
of North Chicago where the answer is a simple technology.
The hospital has
been part of the national VA effort to implement a BPOC
system known as Bar
Code Medication Administration (BCMA).
According to Kay Willis, chief of pharmacy for the North
Chicago VA center,
this system has reduced their medication errors by as
much as 87 percent.
"There's been an improvement in medications
administered on time," she says.
"We have eliminated wrong-patient errors, we have
eliminated wrong-drug
errors and wrong-dose errors."
Newsweek reporters went further to explore why BPOC
systems are in place at
hospitals around the country. They found that the root
cause is a lack of
manufacturer-provided barcode labeled immediate container
packages. In-house
labeling requires more time and money, and may increase
the chance of
mistakes by the pharmacist who is sorting and labeling
the medications,
Newsweek reported.
The article cited healthcare expert Gary Mecklenburg, CEO
of Northwestern
Memorial Healthcare System and former chairman of
trustees for the American
Hospital Association, saying that barcoding is a great
idea and important
for patient safety.
He also believes that it will take collaboration on the
part of hospitals and manufacturers to make the system
effective and
efficient. Link: http://stacks.msnbc.com/news/795131.asp
IV SYSTEMS EMERGE TO ADDRESS PROPOSED FDA BAR CODE
REQUIREMENTS
B. Braun Medical Inc., Alaris Medical Inc. in partnership
with McKesson and
Baxter Corporation are all working to bring greater
barcode-enabled safety
to intravenous medication administration. As with other
medications,
barcoding can be used with IV fluids to ensure the
"right" patient is
receiving the "right" drug in the
"right" dose from an "authorized"
clinician. Varying levels of clinical decision support
can also provide for
automated checks and balances that improve the manual
procedures for dose
calculation and pump programming.
Inaccurate manual programming of intravenous pumps is a
common and serious
problem. B. Braun and others are addressing this
error-prone step.
Likewise, errors will become less likely as an FDA rule
is set in place to
require manufacturer barcode labels pre-mixed solutions,
eliminating the
need to manually label the most common IV medications in
the pharmacy.
VA RECEIVES TOP AWARD FROM AMERICAN PHARMACEUTICAL
ASSOCIATION
AHA News Now July 12, 2002
The American Pharmaceutical Association Foundation gave
its Pinnacle Award
to the Department of Veterans Affairs for the VA's
innovative Bar Code
Medication Administration program. The program was
designed to eliminate a
host of problems like poor handwriting and lost paper
prescriptions.
Link: http://www.va.gov/opa.
NPSF LIST SERV LIGHTS UP OVER PATIENT IDENTIFICATION
DEBATE
Following the JCAHO announcement of the 6 national
patient safety goals for
2002, the first of which is positive patient
identification, the
participants on the National Patient Safety Foundation
list serv began a
lengthy and informative conversation on the topic.
Highlights include:
"A bar coded system can improve accuracy greatly but
it can't guarantee 100%
accuracy. A patient can still get a wristband with the
wrong bar code. The
medication, blood or whatever can also have an incorrect
bar code. Every new
technology and new process produces the opportunity for new
errors. They can
be tremendously helpful but we still need to anticipate
problems."
Frances Stewart, MD, CAPT, MC, USN, Office of the
Assistant Secretary of
Defense (Health Affairs)
"As long as the specimen is drawn using the bar
coded patient identifier on
the wristband, the results will be reported against the
same identifier,
thereby insuring the link back to the patient from which
the specimen was
drawn.
Bar coding patients upon admission, and utilizing the bar
code as the
identifier for ALL processes will insure 100%
accuracy."
Dick Stone, Healthcare ID
"Just an observation: Bar coding can also be defeated by designs that allow
it to be bypassed."
Gail A Shulby, Duke University Medical Center
To follow the entire discussion, go to:
http://www.npsf.org/html/join_in.html and register.
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CAUSE FOR CONCERN
******************************************************
SURVEY REVEALS PATIENT CONCERNS ABOUT MEDICATION-RELATED
ISSUES
PR Newswire, Wednesday, July 17, 2002
According to a new survey conducted by the American
Society of Health-System
Pharmacists, Americans are concerned about
medication-related issues, such
as drug interactions and medication errors, when entering
a hospital or
health system. The national survey found that 85 percent of Americans
are
concerned about at least one medication-related
issue. The top two
concerns cited by respondents were:
-- Being
given two or more medicines that interact in a negative way (70
percent),
-- Being
given the wrong medicine (69 percent),
ASHP commissioned the poll of 1,004 adults nationwide
between May 1 and 5,
2002.
Link:
http://www.ashp.org/public/news/ShowArticle.cfm?id=2996
FAIRVIEW RIDGES HOSPITAL CITED IN MORPHINE DEATH
Minneapolis Star Tribune, Jul 25, 2002
Edward Kyllonen, age 37, died just hours after elective
hip surgery in
November 2001 at Fairview Ridges Hospital in Burnsville,
MN. Many month
later state health investigators have concluded Kyllonen
received a
potentially toxic dose of morphine after his operation,
and that the
hospital and two nurses were negligent in the case. In a
report released by
the Minnesota Health Department, investigators found that
nurses failed to
properly monitor Kyllonen overnight as he continued to
receive morphine and
other painkillers. The overdose came to light after
Kyllonen's widow sought
an investigation by the state's Office of Health Facility
Complaints.
According to the Minneapolis Star report, Kyllonen
underwent surgery to
replace a hip that had been damaged in a snowmobile
accident in February
2001. He died Nov. 3, 2001, a week before his first
wedding anniversary. His
wife, who was three months pregnant at the time, gave
birth to a baby girl
in May.
CHEMOTHERAPY OVERDOSE AT JOHNS HOPKINS
Washingtonpost.com, Thursday, August 1, 2002; 7:00 AM
Chemotherapy overdoses were given to two children being
treated at Johns
Hopkins Children's Center, including a critically ill
2Ω-year-old boy whose
overdose may have caused him to go deaf, health officials
said.
The boy who lost his hearing received twice the correct
dose of the cancer
chemotherapy drug carboplatin on three successive days
two months ago, the
state health department said. Another child, identified as a young girl,
also was given an overdose accidentally, but the dose was
corrected after
one treatment and no harm was done, the agency said.
Hospital spokesman Gary Stephenson issued a statement
acknowledging the
error. He
said the hospital had "multiple systems in place" to make sure
doses are correct. The hospital discovered the
prescription error that lead
to the overdose during a routine check. The discovery prompted hospital
officials to review dosages for five other patients, and
that review turned
up the second overdose.
DRUG-RELATED VISITS TO THE EMERGENCY DEPARTMENT: HOW BIG
IS THE PROBLEM?
Pharmacotherapy, Payal Patel, Pharm.D., Peter J. Zed,
Pharm.D
.
The authors of this study set out to review the
literature concerning
drug-related problems that result in emergency department
visits, estimate
the frequency of these problems and the rates of hospital
admissions, and
identify patient risk factors and drugs that are
associated with the
greatest risk.
They found that as many as 28% of all emergency department
visits were drug related. Of these, 70% were preventable,
and as many as 24%
resulted in hospital admission.
Drug classes often implicated in drug-related visits to
an emergency
department were nonsteroidal anti-inflammatory drugs,
anticonvulsants,
antidiabetic drugs, antibiotics, respiratory drugs,
hormones, central
nervous system drugs, and cardiovascular drugs. Common
drug-related problems
resulting in emergency department visits were adverse
drug reactions,
noncompliance, and inappropriate prescribing.
The authors concluded that drug-related problems are a
significant cause of
emergency department visits and subsequent resource use.
Primary caregivers,
such as family physicians and pharmacists, should
collaborate more closely
to provide and reinforce care plans and monitor patients
to prevent
drug-related visits to the emergency department and
subsequent morbidity and
mortality.
Link:
http://www.medscape.com/viewarticle/439814?mpid=4001&WebLogicSession=PZM7iOb
Cs3HUQ8x5AQ4I25h0KygjXso9Nf2b4T5wjstwwmkbBKho|9174254445529616894/184161392/
6/7001/7001/7002/7002/7001/-1 (registration required)
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GRANTS & FUNDING
******************************************************
RESEARCH GRANTS ARE AVAILABLE FROM ASHP FOUNDATION
ASHP NewsLink, August 20, 2002
The ASHP Research and Education Foundation will award up
to three $100,000
grant through the research grant program, which this year
focuses on the use
of technology to improve patients' safety.
Link: http://www.ashpfoundation.org/Grant-Med-safety.htm
HRSA AWARDS NEARLY $50 MILLION TO HOSPITALS, OTHERS TO
IMPROVE QUALITY
AHA News Now, August 19, 2002
The Health Resources and Services Administration
announced it has awarded 73
grants totaling $48.9 million to better equip hospitals
and other health
care facilities to deliver high-quality medical care.
Grants range from
$29,538 to $3.9 million. For a complete list of facilities and award
amounts, go to http://newsroom.hrsa.gov/
FRAUD AND ABUSE MONEY FOR PATIENT SAFETY TECHNOLOGY?
HHS Secretary Tommy Thompson called for a new law using
fraud and abuse
money to fund technology for hospitals. Speaking at the
federal and state
issues assembly of the National Conference of State
Legislatures' annual
meeting in Denver, Thompson questioned why grocery stores
are more
technologically advanced than some hospitals. He said
potential legislation
should be similar to the unprecedented Hill-Burton Act of
the 1940s, which
launched a nationwide hospital-building program designed
to provide the
necessary number of staffed hospital beds per 1,000
people throughout
America.
******************************************************
EVENTS
******************************************************
Archived Video Pediatric Patient Safety Conference
Available
AHRQ Electronic Newsletter Issue 65
Nearly 600 researchers, clinicians, and others
participated in an
interactive AHRQ-sponsored Child Health Speaker Series
Web conference on
July 17 on methods for reducing errors in pediatric
medicine and
implications for research and practice.
The video and related materials are available at:
http://66.77.20.158/ahrq/childhealthwebconf/
Partnership Symposium 2002: Smart Designs for Patient
Safety
October 14-16th Omni Shoreham, Washington, DC
The finalized agenda for Partnership Symposium 2002 and
other recent updates
are available at www.p4ps.org.
NPSF and ASQ Patient Safety Leadership Summit
October 23, 2002 - San Jose, CA
The Summit features presentations on methodologies to
improve patient
safety, including case studies of the application of Six
Sigma at Froedtert
Memorial Lutheran Hospital in Milwaukee, and Commonwealth
Health Corporation
in Bowling Green, Kentucky.
Link:
http://www.asq.org/subjects/healthcare/npsfsummits.html
AMA/AHRQ Forum on Clinical Quality Improvement
October 30, 2002 at the Chicago Marriott O'Hare
The American Medical Association and AHRQ are sponsoring
a 1-day Clinical
Quality Improvement Forum.
Link: http://www.ama-assn.org/ama/pub/category/3700.html
for registration
information.
4th Annual Wisconsin Patient Safety Forum
November 8, 2002, Oshkosh, WI
The Wisconsin Patient Safety Institute will host the
Fourth Annual Wisconsin
Patient Safety Forum.
For registration information contact
patientsafety@wismed.org.
8th Annual International Scientific Symposium on
Improving the Quality and
Value of Health Care
December 9, 2002 in Orlando, Florida.
This symposium is part of the Institute for Healthcare
Improvement's
National Forum.
IHI is currently soliciting abstracts for presentations.
Abstracts are due by September 6.
Link: http://www.ihi.org/conferences/natforum/index.asp
JCAHO 2002 National Conference on Quality & Safety in
Health Care
Dec. 11-13, 2002 -- Palmer House Hilton -- Chicago IL
The Joint Commission on Accreditation of Healthcare
Organizations (JCAHO)
announced plans for its 2 Ω day National
Conference.
Link:
http://mailiwant.com/links.jsp?linkid=1780&subid=253457&campid=6015
VA Patient Safety Training
January 13th-16th, Las Vegas, Nevada
The VA National Center for Patient Safety is providing a
three-day patient
safety training.
Link: http://www.patientsafety.gov/
Sutter Expert to Speak at HIMSS Conference
Feb. 9-13, 2003, San Diego Convention Center, San Diego,
Calif.
On Mon., Feb. 10, from 4:30-5:15 pm HIT expert John Hummel
will discuss
barcode technology in Room #11B as part of the HIMSS
Vendor Product
Sessions. Hummel is CIO/VP of Information Technology for
Sutter Health, a
leading not-for-profit network that includes 26 hospitals
in Northern
California. Sutter recently contracted with Bridge
Medical to implement the
MedPoint Patient Safety System.
Link:
http://www.himss.org/ASP/ContentRedirector.asp?ContentId=15306
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BRIDGE NEWS
******************************************************
NC HOSPITAL FIRST TO "GO LIVE" WITH BRIDGE'S
THIRD GENERATION MEDPOINT
SYSTEM
BW HealthWire, Aug. 1, 2002
NorthEast Medical Center is the first in the U.S. to
"go live" with the
third generation version of the MedPoint(TM)
barcode-enabled point-of-care
(BPOC) patient safety system from Bridge Medical.
"This new web-enabled MedPoint 3.0 software takes
proven technology --
tested for years at hospitals around the country - to the
next level," says
Keith McNeice, vice president and CIO of the 457-bed
Concord, N.C.,
hospital.
NEMC went live with 11 compact MedPoint units that nurses
wheel into patient
rooms as needed. The hospital expects to have 70 or more
when it completes
rollout by end of Q1 2003.
"We launched MedPoint in our largest unit where
patients stay longer and
receive many medications," explains Barry W.
Hawthorne, RN, MSN, CNAA,
NEMC's vice president, patient care services.
"Scanning medications at the
bedside avoids errors caused by 'look-alike/sound-alike'
drug names,
misplaced decimal points, and other common sources of
confusion. MedPoint
gives our patients an electronic safety net that
complements the critical
thinking skills and judgment of our nurses."
Link: http://www.bridgemedical.com/news_2002_23.shtml
IN THE NEWS: SACRED HEART MEDICAL CENTER
An article on Inland Northwest Health Services and Sacred
Heart Medical
Center, "Washington Hospitals Deploy New Patient
Safety Technology" appeared
in the July 29 For the Record.
The
contract will eventually impact the safety of million-plus
medication administrations annually, explains Sacred
Heart CEO Ryland "Skip"
Davis. "In light of our success with Bridge, our
sister hospitals have
elected to deploy MedPoint, too."
"Our
pharmacists are pleased with the system," says Sacred Heart
Director of Pharmacy Larry Bettesworth, PharmD, RPh,
"because it will give
nurses and pharmacists more time to devote to patients.
MedPoint
automatically generates an electronic Medication
Administration Record
(eMAR) as well as other reports that reduce paperwork.
Even our risk
managers now have a few less risks to worry about."
Adds Sacred Heart VP of Nursing Carol Sheridan, RN:
"MedPoint makes patients
feel more secure knowing there's a system in place to
double-check they get
the right drug, the right dose, at the right time. And
our nurses feel
better knowing the software will alert them to
look-alike, sound-alike
medication packaging and labeling, and other possible
hazards."
In addition to clinical effectiveness, CIOs like Galusha
look for ease of
integration to existing systems. "Bridge uses 'open
architecture' design, a
feature that makes MedPoint easy and inexpensive to
interface with such
software as the Meditech Magic system our INHS hospitals
use. When you
oversee IT for 27 hospitals, working with a vendor like
Bridge eliminates
the integration headaches that drive CIOs crazy."
MR. DOUGLAS GOES TO WASHINGTON!
Jim Douglas, R.N., site coordinator at Northern Michigan
Hospital was
invited to present at the Partnership Symposium 2002:
Smart Designs for
Patient Safety in October. Jim's proposal highlighting Northern Michigan's
use of the Bridge Medpoint system was selected from more
than 100 submitted.
BRIDGE COO AND BOARD MEMBER FEATURED ON HIMSS NEWSBREAK
HIMSS NewsBreak, Sept. 2-16, 2003
Sutter CMO Gordon Hunt, MD, Bridge COO Rusty Lewis,
discuss patient safety
and barcoding.
Link: http://www.bridgemedical.com/media_coverage.shtml
BRIDGE CITED IN FUTURESCAN 2002
Bridge was listed as a vendor of note in ACHE/AHA:
Futurescan 2002: Patient
Safety Technology by Russell C Coile, Jr.
"With the encouragement of the Leapfrog Group and
the IOM, many hospitals
are stepping up their investments in technology to
promote quality outcomes
and improve patient safety. Four in five Futurescan panel
members agree that
more than 60 percent of U.S. hospitals will invest in
technology such as
computerized medication order-entry systems to reduce
medical errors in the
next two to five years (see Table 6). San Diego-based
Bridge Medical Systems
offers a computer-based medication dispensing system that
can reduce
medication errors by more than 50 percent, with a cost
savings potential of
$2,500 to $3,500 per bed. Technology is more than a
"quick fix" for the
safety issue. Providers must reengineer processes and
systems for a total
solution."
--