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For other articles and previous issues click here. March 7, 2005 Preventing
Medication Errors A comprehensive patient medication list will be a JCAHO standard beginning next year. Beyond Radiology An innovative approach to reducing medication errors in healthcare facilities nationwide became a JCAHO goal for hospitals effective January 1. And the long-term effects could have significant positive financial and patient care ramifications. Initially developed by a team of healthcare professionals at Luther Midelfort-Mayo Health System in Eau Claire, Wis., this process reduces medication errors by ensuring that hospital staff treating a patient are aware of all the patient’s medications, not just those treating the illness at hand. This policy will be adopted as an official JCAHO standard beginning January 1, 2006. “We weren’t looking for a specific solution, but it was a collaborative effort initiated through the Institute for Healthcare Improvement [IHI],” said team leader Roger Resar, MD, of Luther Midelfort. “A nurse is confronted with these medication issues daily, and rather than working with a haphazard process, we developed a standardized, repeatable process.” The process helps clarify physician instructions in regard to medication. Resar said it took six months to initiate the process in 1997 and 1998, but it can be formulated faster for those hospitals that utilize electronic medical records (EMRs). Resar estimated that 400 to 500 hospitals nationwide have used this process. “There was a tremendous success rate in reducing adverse effects, and this success was repeated in hospitals around the country,” he said. Resar estimated that the number of adverse drug effects was reduced by 15%, a similar reduction when compared to hospitals that utilized a similar process with a focus on an EMR. “Our process, of course, costs significantly less [than an EMR] for similar results and you can use this process in part and parcel of integrating with electronic records,” he noted. Since 1992, the FDA has received roughly 20,000 reports of medication errors. These are voluntary reports, so the number of medication errors that actually occur is thought to be much higher. There is no “typical” medication error, and everyone from health professionals to patients and their families is involved. The array of medication errors reported to the FDA may stem from poor communication, misinterpreted handwriting, drug name confusion, lack of employee knowledge, and lack of patient understanding about a drug’s directions. “But it’s important to recognize that such errors are due to multiple factors in a complex medical system,” said Paul Seligman, MD, director of the FDA’s Office of Pharmacoepidemiology and Statistical Science. “In most cases, medication errors can’t be blamed on a single person.” Reporting Errors The Luther Midelfort team developed its procedure while participating in a collaborative improvement program organized by the IHI, which focused on redesigning systems to reduce adverse medication events. The IHI subsequently made it a standard feature of its ongoing work. Lucian Leape, MD, a preeminent patient safety expert and IHI fellow, arranged for it to be tested on a statewide basis in Massachusetts before being proposed to JCAHO. The team proposed that a list of all the patient’s medications (even for unrelated illnesses) be compiled and reconciled to ensure that the patient is given (or prescribed) the right medications at the correct dosages—at admission, discharge, and before transferring a patient to another care unit. Metropolitan (Metro) Hospital in Grand Rapids, Mich., is one facility where the policy has been implemented. Metro has focused on medication safety for several years. “We had a very effective medication safety team in place before we joined IHI,” said Regina Ricketts, RN, Metro’s quality management coordinator. “We were already working our way through the 194 safe practices identified by the Institute for Safe Medication Practices [ISMP] in 2000.” (Based in Huntington Valley, Pa., the ISMP is a nonprofit organization that provides education about adverse drug events and their prevention.) Focus on Safety “We meet regularly as a community to share our successes and struggles,” Ricketts said. “We are competitors, but we have always had good relationships, and we have pursued a number of joint ventures together through the years. It’s good for us and good for our community.” Ricketts said the hospital’s focus on medication safety enabled it to bring its total compliance rate with the ISMP practices to 86.7% in two years’ time. But, she said, it still wanted to bump its commitment up a notch. So in 2003, Metro joined IMPACT and enrolled in an IHI Medication Safety Collaborative. When implemented at Luther Midelfort, this approach reduced medication errors by 50% and adverse drug events (ADEs; causing harm to the patient) by 20%. The aim was to decrease the number of ADEs and potential ADEs by 60% in the Telemetry/Intermediate Care Unit. Measures used included both discrepancies from unreconciled medications per 100 admissions (potential ADEs) and the number of actual ADEs per week. Medication errors snared headlines in 1999 when the Institute of Medicine (IOM) released “To Err is Human: Building a Safer Health System.” According to the report, medical errors cause between 44,000 and 98,000 deaths per year. It is estimated that more than 7,000 deaths annually are related to medications. In response to the IOM’s report, all parts of the U.S. health system made error reduction a top priority by reevaluating and strengthening checks and balances. Also, the FDA has developed a number of additional strategies designed to reduce medication errors, including the following: • Bar code label rule: After a public meeting in July 2002, the FDA decided to propose a new rule requiring bar codes on certain drug and biological product labels. Healthcare professionals would use bar code scanning equipment—similar to that used in supermarkets—to make sure that the right drug in the right dose and route of administration is given to the right patient at the right time. “It’s a promising way to automate aspects of medication administration,” said Robert Krawisz, executive director of the National Patient Safety Foundation. “The technology’s impact at VA [Department of Veterans Affairs] hospitals so far has been amazing.” The VA already uses bar codes nationwide in its hospitals, and the result has been a drastic reduction in medication errors. For example, the VA medical center in Topeka, Kan., has reported that bar coding reduced its medication error rate by 86% over a nine-year period. • Drug name confusion: To minimize confusion between drug names that look or sound alike, the FDA reviews approximately 300 drug names per year before they are marketed. Computerized programs assist in detecting similar names and help physicians take a more scientific approach to comparing names. • Drug labeling: Consumers tend to overlook important label information on over-the-counter (OTC) drugs, according to a 2002 Harris Interactive Market Research Poll conducted for the National Council on Patient Information and Education. In May 2002, an FDA regulation went into effect that aims to help consumers use OTC drugs more wisely. The regulation requires a standardized Drug Facts label on more than 100,000 OTC products. Modeled after the Nutrition Facts label on foods, the label helps consumers compare and select OTC medicines and follow instructions. The label clearly lists active ingredients, uses, warnings, dosage, directions, inactive ingredients, and other information, such as how to store the medicine. • Error tracking and public education: On March 13, 2003, the FDA announced a proposed rule that would revamp safety-reporting requirements. For example, the proposal would require that reports on actual and potential medication errors be submitted to the agency within 15 calendar days. The rule is part of the FDA’s efforts to better understand the sources of medication errors while simultaneously preventing them. The FDA reviews medication error reports that come from drug manufacturers and through MedWatch, the agency’s safety information and adverse event reporting program. The agency also receives reports from the ISMP. There were many challenges realized by the Luther Midelfort team. One of the most notable barriers is to impress upon an overworked and often understaffed nursing staff the importance of such a system. But Resar said that, on average, it takes 11 minutes for a nurse to finish a medication reconciliation form. Resolving Issues • Assumption that the responsibility lies with the physician rather than the nurse or pharmacist. Resar said not all physicians understand medications in fields outside their own expertise and that a nurse might have a better handle on some of this information. • Setting up the process for every patient who checks into a hospital can be a time-consuming and procedural challenge, but the hospital will experience success only if all patients undergo a medication reconciliation. • Hospitals that already utilize EMRs may experience significant challenges because the introduction of added technology could confuse the process. But Resar said once these difficulties are overcome, this reconciliation works well with EMRs. • The perception that any medication list must be perfect is inaccurate. Resar said that is the underlying goal, but as the process is first introduced, information may not always be perfect. For example, some patients may not know the name(s) of the medication(s) they are taking. Resar said one of the most important aspects of a medication reconciliation is the discharge process. If a patient is discharged with wrong medications, it can lead to significant problems for not only the patient but also the hospital, physicians, and nurses. When the Luther Midelfort team reviewed its patient records, it found that medications not reconciled at transition points might account for as much as 50% of all medication errors and up to 20% of ADEs seen both in the hospital and in later outpatient settings. This was a powerful incentive for the team to improve the process of reconciling medications. As a result of those findings, the team also: • developed a tool for reconciling medications at admission, identifying discrepancies, and capturing documentation that reduced the need for nurses and pharmacists to contact physicians for clarification; • redesigned the discharge process with new forms that require a review for reconciliation of medications to ensure that patients left with accurate discharge instructions and medication orders; • required a reconciliation review of each patient’s Medication Administration Record (MAR) during transfer between patient care units to ensure medications were not inadvertently omitted; • recruited a team to redesign (ie, error-proof) the MAR form; • set up a quality audit of the reconciliation review process and data reporting procedures; and • started performing medication reconciliation during admissions to the critical care unit. Resar said that by implementing a system to ensure that medication orders were reconciled, processes were improved to help reduce both potential and actual ADEs and exceed the team’s goal. By adding reconciliation at all transition points—admission, transfer, and discharge—Resar believes his team enjoyed a greater amount of success had all three not been addressed. From its experience, the Luther Midelfort team has gained a number of valuable lessons. Hospitals that implement the system should start with small, incremental tests of change. Resar believes this is the best approach to undertaking such a sizable project. He recommended that all members of the patient care team be included in the process of medication reconciliation. No single group—nurses, pharmacists, or physicians—should be responsible for ensuring that it works. Likewise, administrators should involve staff members and medical education departments early in the change process to help develop the tools to sustain the process with new staff and providers. Finally, Resar believes it is important to measure and report all results, which makes sustaining and expanding the project possible. “It’s simply a better way of providing patient care,” he said, “and it will reduce the number of headaches caregivers will experience on a daily basis.” — Mike Scott is a freelance writer who has contributed to more than 70 magazines, newspapers, and Web sites on numerous topics—from business to healthcare to technology. |
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