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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

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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

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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.

 

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EVENTS

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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."

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