Advances in Patient Safety

Hospital Uses “Storytelling” Approach to Prevent Medication Errors

February 13, 2014 | Lebowitz & Mzhen

A hospital in Houston, Texas has adopted a “narrative-based approach” of communicating the details of medication errors to hospital staff (login required). A medication safety consultant employed by the hospital found that the prior approach, which relied on unit managers to pass along information to their teams, was not leading to greater institutional knowledge about how to avoid medication errors. The new approach involves the production of short videos detailing the issues that led to a specific medication error. The success of the program is difficult to measure, as it is based solely on self-reporting by hospital leaders who seemed to perceive a substantial reduction in medication errors during the eight-month pilot program. The program bears some similarities to how many attorneys approach claims for pharmacy and medication errors, as a narrative story told to the judge and the jury.

MD Anderson Cancer Center ran a pilot program from October 2012 to June 2013. Every month, a team consisting of a nurse, a pharmacist, and a patient safety specialist would review recent medication errors to identify important concerns. They would decide on three events or issues, and another multidisciplinary team would pick one to use in a video. The hospital’s communications department would handle the actual production, including writing a script, shooting and editing the video, and formatting it into a PowerPoint presentation.

Once the hospital administration approved the final video, it would be uploaded to the hospital’s intranet. The hospital’s various department heads and team leaders would be notified of the new video. The leaders would then be responsible for showing the video to their teams. The hospital produced one video a month for eight months. Hospital leaders reportedly accessed the videos more than 3,500 times during that period, and eighty-three percent of them showed the videos during staff meetings. A majority of leaders said in survey responses that the videos were a “very” or “extremely” successful means of communication. The hospital permanently adopted the program, and has expanded it to share other information besides medication errors.

Robots May be the Answer to Decreasing Contamination and Error in IV Compounding

May 20, 2013 | Lebowitz & Mzhen

Following the widespread contamination problems at several compounding facilities, hospitals and pharmacies have begun to reevaluate the potential options for improving sterility and quality of compounded IV fluids and related products.

One potential option is the use of robots in lieu of pharmacists or technicians. One such robot is called RIVA, a fully automated IV compounding robot. The vice president of marketing at the company which sells RIVA stated that hospitals were already expressing an interest in their product prior to the contamination issues, but that interest had piqued following the incidents.

The primary draw of such automated systems is the fact that it minimizes the potential for human error, given the fact that there is very little human manipulation involved in the process. In essence, an individual inputs the stock drug vials, the bags to be filled, empty syringes, and whatever other components may be required, sets the parameters for production, presses the start button, and then takes the finished and labeled mixed bags or syringes from the output chutes. Thus, in addition to lowering the chance for human error in actually compounding the drugs, there is also a considerably lower chance of contamination, since the robots contain an aseptic environment, and the only touching happens before and after the mixing has occurred.

Additionally, the RIVA machine in particular has multiple accuracy checks in place. These include:

weighing of drug vials before and after use
weighing of syringes prior to and following filling
comparison of photos of drug labels with file photos, and
bar code scanning

Preparations failing any of these tests are automatically rejected by the machine. Additionally, pulsed ultraviolet light flashes at vials throughout various sanitation points. Throughout periodic testing for contamination following installation of a RIVA unit has failed to produce a single positive culture thus far.

The unit operates 18 to 22 hours daily, during which time it can fill approximately 400 to 500 syringes. The robot can be programmed to produce batches of individualized patient specific doses, or larger batches of the same drug and dose. According to IHS, the company who sells RIVA, preparing 350 syringes for the machine requires approximately three hours of a technician’s time.

Johns Hopkins Study Recommends Training of Nurse-Pharmacist Teams to Review Patient Drug Regimens, as a Way to Prevent Medication Errors

August 8, 2012 | Lebowitz & Mzhen

Serious complications and injuries can result from discrepancies between the medications patients take at home, the medications they receive in the hospital, and the medications they take home with them. To prevent such medication errors, a recent study out of Johns Hopkins recommends that hospitals train teams of nurses and pharmacists to reconcile patients’ medication lists. Such teams could better ensure that patients receive consistent medications and dosages, at a lower cost to both the hospital and the patient, thus improving overall health and safety for hospital patients.

The Journal of Hospital Medicine published the study, entitled “Nurse-pharmacist collaboration on medication reconciliation prevents potential harm,” in its May/June 2012 issue. The purpose of the study was to test how “medication reconciliation” could help prevent “adverse drug effects” (ADEs). The study involved over five hundred patients at a “1000 bed urban, tertiary care hospital” from January 2008 through March 2009. Nurses would conduct an interview with patients to obtain a home medication list (HML), outlining all medications regularly taken by the patients. Patients often forgot or otherwise omitted some medications during this process, or were unable to remember the name or dosage of a drug. Some patients could only provide a description of the drug’s appearance, and many were not certain what condition a particular drug treated. Discrepancies between the medications a patient was actually taking and those they received during treatment and upon discharge occurred in forty percent of hospital visits, according to the researchers.

Hospital Uses RFID Tags to Keep Track of Emergency Room Drugs

July 26, 2012 | Lebowitz & Mzhen

Hospitals must regularly contend with medical emergencies, such as heart attacks or allergic drug reactions, that require an immediate response. Hospitals maintain supplies for such emergencies, known as “crash carts,” that contain equipment and medications for diagnosing and, if necessary, reviving patients. Monitoring and maintaining the crash carts requires the careful attention of hospital staff. New technologies, however, allow hospitals to track crash cart inventories more efficiently. One Baltimore hospital is using radio-frequency identification (RFID) tags to ensure that crash carts are fully stocked with necessary drugs, and that all of the drugs are up-to-date.

A typical crash cart includes multiple shelves and trays, all of which must be carefully and consistently organized. Each crash cart has a cardiac monitor and defibrillator, equipment for intubating a patient, and other associated materials. The nine trays in each cart at the University of Maryland Medical Center in Baltimore contain a variety of drugs for emergency use. One tray could have anywhere between twenty-five and seventy-five items. Maintaining a supply of available equipment and drugs, and making sure the drugs are not expired, is critically important for patient safety.

Study Suggests that Electronic Medical Records Can Reduce Error Rates

July 5, 2012 | Lebowitz & Mzhen

Electronic health records (EHRs), used in place of voluminous paper records, may significantly reduce the risk of errors, and therefore medical malpractice claims. This finding is from a study published in the June 25 online edition of the Annals of Internal Medicine. Doctors have been very slow to adopt many newer technologies, including EHRs. Much of the hesitance is driven by concerns over the cost of switching to electronic systems, but also over concerns about how doctors’ ethical duties to their patients. In particular, effectively protecting patients’ privacy while using newer computer technologies remains difficult. The study, while limited in scope, offers support to the idea that use of EHRs may help prevent medication errors and other types of malpractice.

EHRs are a digital version of personal health records. In addition to personal identifying information like date of birth, they may include dates of treatment, results of tests, dates and descriptions of surgeries and illnesses, prescription medication history, and family medical history. Under state and federal privacy laws, this information is highly confidential, with severe penalties for medical professionals who breach privacy. EHRs offer the benefit of making comprehensive information easily accessible to a treating physician. Sophisticated systems may even alert a doctor or pharmacist of potential drug interactions with a new prescription. The downside, of course, is that a patient’s entire medical profile may be vulnerable to theft, or may be compromised by data or equipment failures.

Study Finds Use of Interpreters in Hospital Emergency Departments Reduces Medication Errors Almost by Half

June 28, 2012 | Lebowitz & Mzhen

A study published recently in the Annals of Emergency Medicine looked at whether the use of a trained, professional interpreter with limited-English or non-English-speaking patients in hospital emergency departments (ED’s) reduced the incidence of medication errors and other mistakes. The study compared situations in which a trained interpreter was present with situations with an amateur translator and situations with no interpreter. Patients who had the assistance of professional interpreters suffered a far lower rate of risky translation errors, particularly errors related to medication dosages. The findings could provide a helpful model for hospitals seeking to reduce pharmacy misfills due to language barriers, and also for other communication barriers like hearing impairment.

The researchers conducted a “cross-sectional error analysis” of ED visits captured on audiotape over the course of thirty months. The visits occurred at two Massachusetts pediatric ED’s. They reviewed fifty-seven meetings between doctors or other medical professionals and Spanish-speaking patients and caregivers with limited English proficiency. Twenty of the visits utilized professional interpreters, and twenty-seven had “ad hoc interpreters.” The remaining ten visits occurred with no interpreters.

In reviewing the fifty-seven meetings, the researchers counted nearly two thousand translation errors. Eighteen percent of those errors had the potential to affect the patient’s treatment. The percentage of potentially harmful errors, when broken down among the three types of meetings, revealed that meetings with professional interpreters had just over half the rate of errors as the other meetings. While twelve percent of the translation errors in visits with professional interpreters were potentially harmful, the rate for visits with amateur translators was twenty-two percent. The rate for visits with no interpreter was twenty percent. Interestingly, the visits with no interpreter at all had a lower error rate than those with an ad hoc translator.

National Patient Safety Board Would Reduce Medication Errors, Say Celebrity Supporters

June 7, 2012 | Lebowitz & Mzhen

The National Transportation Safety Board (NTSB), the federal agency that reviews highway and aviation accidents and makes recommendations for safety regulations, could serve as a model for an entity to monitor patient safety, according to a number of celebrities and other advocates. A medical journal article co-authored by actor Dennis Quaid and airline pilot Chesley B. “Sully” Sullenberg III argues for the creation of such an entity to apply lessons of previous medication errors and other mistakes towards the prevention of future problems. They cite the NTSB’s success at recommending effective revisions to airline safety regulations.

In an article published in the March 2012 issue of the Journal of Patient Safety, Quaid and Capt. Sullenberg join a medical doctor and an attorney in calling for creation of a safety board for patients. All four authors have experience as jet pilots, and all four have experience in aviation safety. Quaid additionally has endured a medical “near-death experience” with his twin children. They describe a “healthcare financing crisis” due in part to inefficient healthcare spending and waste, based on decisions made by corporate boards and administrators rather than doctors. They recommend adoption of “best practices” based on past experience, similar to the way the aviation industry has improved safety with the assistance of the NTSB.

Electronic Prescriptions Help Doctors and Pharmacies Avoid Medication Errors, Prevent Fraud and Abuse

May 31, 2012 | Lebowitz & Mzhen

Handwritten prescription slips have always presented risks to patients. The risk of a pharmacist or pharmacy technician misreading a doctor’s handwriting, sometimes known as “chicken scratch” among pharmacists, leads to the risk of a misfilled prescription. This could involve the wrong dosage of a drug, or the wrong medicine entirely, with the consequences ranging from adverse side effects, worsening of a patient’s condition, or even death. New computerized systems for doctors and other medical professionals, however, join the ever-increasing number of electronic solutions to common human errors. These systems can help combat not only pharmacy errors, but also prescription fraud and prescription drug abuse.

Electronic prescriptions, or e-prescriptions (e-Rx), allow a doctor to write a prescription by submitting a request to a pharmacy online, rather than writing out the prescription on a prescription pad. A 2010 study mentioned by the New York Times, which examined handwritten prescriptions from doctors, physician assistants, and nurse practitioners in New York, found a thirty-seven percent error rate for handwritten prescriptions, not including legibility errors. The study found legibility errors in eighty-eight percent of the handwritten prescriptions. These errors can result in a patient receiving the wrong dosage or the wrong medication. They may also result in the pharmacy needing extra time to consult with the prescribing doctor or professional to sort the matter out, which could cause harm to a patient in urgent need of a particular medication.

Congress promoted the use of e-Rx in the 2009 Health Information Technology for Economic and Clinical Health Act (HITECH Act), passed as part of that year’s economic stimulus bill. The HITECH Act establishes certain acceptable uses for electronic medical records, giving regard to issues of patient privacy and the security of patients’ personally identifying information. It specifically names e-Rx as an approved use.

Pharmacist Institutes Program of Double-Checking Discharge Papers, Cuts Hospital Pharmacy Errors to Near Zero

February 8, 2012 | Lebowitz & Mzhen

The hospital pharmacy services director at Minnesota’s Hennepin County Medical Center, Bruce Thompson, noticed several years ago that his staff would often discover medication errors when patients returned to the hospital after treatment. The Minneapolis Star-Tribune recounted the story of a patient who left the hospital after a kidney transplant with incorrect dosage instructions for the prescribed antibiotics. The hospital discharged a patient who had been treated for a pulmonary embolism without an essential blood thinner. Thompson wondered how common such mistakes were at the hospital, so he enlisted some colleagues to review thirty-seven patients who had been discharged from the hospital to area nursing homes during a three-month period at the end of 2008 and beginning of 2009

Thompson discovered that only three of the thirty-seven cases he reviewed had no problems. That meant an error rate of ninety-two percent, with about a third of the errors deemed “likely harmful.” The most common errors included prescriptions with incorrect dosages and duplicates or omissions of medications at discharge.

To reduce the surprisingly-high rate of errors, Thompson and the hospital administration had pharmacists review all patients’ discharge orders before the patients left the hospital. This allowed the pharmacy one last opportunity to spot mistakes and notify the patient’s doctor to resolve the problem.

According to the hospital’s report, the rate of errors dropped to almost none nine months after they started pre-release review by pharmacists. This also reduced the hospital’s readmission rate to around five percent, meaning far fewer patients were returning to the hospital for additional treatment after their discharge.

The Institute for Safe Medication Practices, which offers education and support to healthcare organizations, gave Hennepin County Medical Center one of its “Cheers” Awards in 2010. This award recognizes people, organizations, or businesses that “have set a superlative standard of excellence” in preventing errors relating to medication errors or drug incidents.

The improvement in patient safety in the hospital pharmacy is welcome news, although it is just one part of a hospital’s operations, and mistakes can occur almost anywhere. Hennepin County Medical Center ranked relatively low, for example, in a review of Minneapolis-area hospitals conducted by the U.S. Department of Health and Human Services that looked at infections resulting from central lines used in critically ill patients. This is a relatively rare procedure, and the hospital still performed above the national average. It nevertheless demonstrates that medication errors and infections do not occur solely in the pharmacies or upon discharge.

Government Promotes Communication Between Doctors and Patients to Reduce Pharmacy Errors

November 28, 2011 | Lebowitz & Mzhen

https://www.youtube.com/watch?v=VuGuYC80XxsThe Agency for Healthcare Research and Quality (ARHQ), an agency of the federal government, has partnered with the Ad Council to promote two-way communication between patients and their doctors as a means of improving care and reducing errors. The campaign currently focuses on public service advertisements targeting clinicians and emphasizing the idea that simple communication with patients can be one of the most powerful diagnostic tools. According to research, patients are more likely to adhere to their treatment plans if they engage in direct communication with their doctors. Communication can also help doctors understand a patient’s condition and make more informed decisions as to medications.

This Pharmacy Error Injury Lawyer Blog has previously reported on various efforts by doctors and hospitals to improve patient safety. Both Maryland and Oregon have shown signs of improvement in communication between pharmacies and state pharmacy boards, leading to successes in both reporting of errors and prevention of future errors in hospitals. The “Good Catch” program, pioneered at Baltimore’s Johns Hopkins, promotes voluntary reporting of errors through internal hospital channels in the hopes of preventing more serious errors before they occur. The program has caught on in other hospitals around the country and has produced positive results.

The ARHQ/Ad Council campaign differs from the above programs in that it is an initiative of the federal government, and therefore has potential to reach doctors, hospitals, and pharmacies nationwide. It also represents a collaboration between the public and private sectors, with the nonprofit Ad Council distributing PSA’s for the ARHQ. The ARHQ is part of the U.S. Department of Health and Human Services. Its mandate is to conduct and support research regarding issues of health care such as safety, quality, cost, and access. It publishes and disseminates this research to clinicians nationwide. The agency also regulates certified Patient Safety Organizations, groups authorized by federal statute to promote reduction of medical errors and improvement of patient safety.