Hospitals bolstering efforts to cut errors

Font Size:

By Ann McGlynn | Monday, July 31, 2006 | No comments posted

When written by hand, the difference between a “u” and a “4” can be indiscernible.

A .2 can appear to be 2, or 2.0 can look like a 20.

If such appearances are deceiving on a prescription medication, the results can be harmful or fatal.

Medicine errors hurt at least 1.5 million people a year, a recent report from the Institute of Medicine of the National Academies says. The errors can happen at any of the steps between doctor and patient.

It is the reason why area hospitals are spending money on new technology, encouraging employees to report mistakes and empowering patients with knowledge.

“There has been a lot of awareness brought to the topic,” said Yvonne Levetzow, pharmacy clinical specialist with Trinity Medical Center. “Patient safety is a key word.”

The report, released earlier this month, cites studies showing 400,000 preventable drug-related injuries happen each year in hospitals, 800,000 in long-term care settings and 530,000 in Medicare recipients in outpatient clinics.

The mistakes cost billions of dollars in extra care alone, the study suggests.

“We need a comprehensive approach to reducing these errors that involves not just health care organizations and federal agencies, but the industry and consumers as well,” said Linda Cronenwett, the University of North Carolina nursing school dean who co-chaired the committee which wrote the Institute of Medicine Report.

Layers of technology

Each night, a robotic system fills the prescriptions for patients at Trinity Medical Center, Levetzow said. Fingerprint technology is utilized on automated medication machines for access. And a new bar-coding system matches the right patients with the right meds at the right time.

A network of newly installed technology last year at Genesis Medical Center initially decreased the rate of medication error, said Jim Lehman, vice president of quality.

One system documents the medications given to each patient, using handheld computers carried by nursing staff. An “ATM of medications” on each unit is a mini-pharmacy of sorts, ensuring the correct medication for each patient, Lehman said. An automated system checks dosages for prescribed medications to ensure they fall within an acceptable range. And in the past couple of weeks, practitioners began entering medication orders on a computerized prescription system to reduce the number of handwritten prescriptions.

No more “u” confused for “4”, no more misleading zeros. However, Lehman cautioned, computerized prescribing does bring with it the need to watch for another type of error: clicking on the wrong option.

Genesis has spent millions of dollars on the technology, Lehman said. But Genesis also recognizes the human factor. The system changed its policy to encourage the reporting of medicine errors.

Since its implementation this spring, the Genesis medicine error rate has increased, he said.

“We want to create a culture that allows people to report without being fearful for negative consequences,” Lehman said. “We’re actually getting more reports of errors than previously. That’s what we wanted. We need to know about these things to deal with them.”

Simply put, errors that are reported can be examined thoroughly and the causes remedied, he said.

Genesis traditionally falls at or below the national average of 3 to 3.5 mistakes per 10,000 doses, Lehman said. The hospitals give out approximately 30,000 doses a month.

Trinity, Levetzow said, stands at about 1.5 mistakes per 10,000 doses. It not only tracks the number, but severity, of mistakes.

The human factor

A nurse from Genesis was recently fired after she neglected to give a patient the proper medications before a blood transfusion, unemployment appeal documents from Iowa Workforce Development show.

The nurse had worked for the health system for six years when “she gave a patient a bag of blood but did not follow the doctor’s orders and give the patient the pre-medications prior to hanging the blood,” documents state. She “had been previously warned about similar patient safety infractions and knew that one more write-up would lead to her termination.”

While a human made the error, another human, a fellow nurse, discovered the medications had not been given, documents state. “Such a medication error can have potentially serious consequences for patients.”

The “human factor” is critical in combating medication errors, said Tom Evans, president of the Iowa Healthcare Collaborative, a newly formed nonprofit organization working to raise the quality of Iowa’s healthcare system.

“One of the most important things you can do is to institute a culture of safety,” Evans said. “Too often we don’t have a culture of safety, we have a culture of blame. If there is a bad outcome, it is always someone’s fault.”

Free sharing of best practices is critical, as is engaging patients in their own healthcare, he said.

“We have entered a new era of transparency and accountability. Best practice is not proprietary information. The intent is to create an Iowa healthcare culture of quality, patient safety and value,” Evans said.

Trinity offers one example of attempting to empower patients. Workers printed 50,000 patient information cards, in English and Spanish, giving specific tips to patients on how to help keep watch over their own medications, Levetzow said.

Evans’ organization is compiling statistics to be released in the fall that will offer specific snapshots on how Iowa’s hospitals are performing in the area of patient safety. No such information is widely available now.

“We want to make sure the information that is out there is used to enlighten providers,” he said. “What we’re trying to do in the healthcare community is to turn the lights on.”

Ann McGlynn can be contacted at (563) 383-2336 or amcglynn@qctimes.com.