Minimizing Mistakes

June 24, 2011
Doris Mulder What ultimately will resolve the vexing problem of medication errors within United States hospitals: training, legislation, a more
Doris Mulder
What ultimately will resolve the vexing problem of medication errors within United States hospitals: training, legislation, a more open culture, a more punitive culture, or new technology? Even before the publication of the landmark Institute of Medicine (IOM) report in 1999, "To Err is Human: Building a Safer Health System," which brought the problem of medical errors out of the shadows, we at Beloit Memorial Hospital (BMH) were working to address this issue.

BMH is a 125-bed hospital that has earned a reputation for excellence thanks to our uncompromising commitment to maintaining the highest level of safety and compassion for our patients. One way we've done this is by being very open minded about the latest technology to help us deliver superior service. We also operate four offsite primary care clinics and serve a population of nearly 200,000 people in Wisconsin and Illinois.

In the late 1990s, an interdisciplinary task force was formed by our leadership team to examine our medication- use process. By creating a flow chart from the time a medication was ordered for the patient, to the point of administration at his or her bedside, to the time of documentation by the nurse, we identified unnecessary steps that could be eliminated from the process, thus reducing opportunity for errors. Since every step in this process represents an opportunity to introduce error, our goal was to eliminate any and all redundant steps.

Realizing that even more could be done to mitigate patient harm, we moved to a more open culture on medication errors in order to shine light on the problem and address the root causes. Our goal was to foster an open dialogue and create a safer environment for our patients. We did this by implementing a non-punitive and completely anonymous error-reporting policy. With that policy in place, anyone who witnessed a medication error or even a close call could report it without fear of discipline. Soon after the policy was implemented, reports of errors and close-calls increased. To us, this was a good sign. It showed that we were taking an honest look at this issue, which gave us a very realistic—if somewhat sobering—picture of the number of medication errors in our hospital. At this point, we decided to invest in technology to improve our processes even more.

After first exploring, but ultimately rejecting, the possibility of a computerized provider order entry system as a possible tool to reduce errors, we decided to focus our attention on the patient's bedside, the point where many medication errors occur and where there is no second check available. With that in mind, it didn't take long for bar coding to emerge as the technology we wished to investigate further. Subsequently, we invited several vendors to demonstrate bedside bar coding technologies.

After those demonstrations, we concluded that BMH needed a solution that could do more than simple medication verification. We needed a solution that could also verify lab-specimen collection, blood transfusions and other procedures. That decision left us with two potential vendors who could fulfill our specific needs. The two finalists offered similar technology capable of achieving the solutions we sought, one platform was a laptop on a mobile cart and the other was a handheld device about the size of a large PDA. Ultimately, we selected the handheld portability and expanded capabilities of Dublin, Ohio-based Cardinal Health's CareFusion application.

Using the CareFusion device, we are able to access an array of applications all designed to ensure the safety of BMH patients. From devices that fit in the palms of their hands, our clinicians are able to make all of the necessary verifications to be certain all patients are receiving their prescribed courses of treatment. Furthermore, all medications administered are seamlessly transferred into the hospital's Meditech (Westwood, Mass.) electronic medication administration record.

The system's base application, Medication Administration, uses bar code scanning on patient ID bracelets and medications to ensure the five rights check for each medication that is administered, whether it is given orally, IV or any other route. Specimen Collection Verification is the feature that allows positive patient identification for lab specimen collection. The application that reduces the potential for errors during the blood transfusion process is called Transfusion Verification. And, Nursing Data Collection captures patients' vital signs and helps disseminate real-time patient information to other team members.

Combined, all of these applications help to improve workflow efficiency for our staff while simultaneously ensuring the safety of our patients.

We implemented CareFusion about four years ago, which has aided our efforts to fight and control the problem of wrong-patient errors. With our non-punitive and anonymous error reporting policy, we believe that our data on medication errors is reliable. Since we began using the system, we have seen an 80 to 85 percent reduction in medication errors and have been able to sustain this decreased level of error incidents.

Since implementing the Specimen Collection Verification application, we have had zero wrong-patient errors with lab specimen collection for more than three years. Prior to implementation, we saw about six to eight wrong-patient lab draws per year.

We plan to expand upon CareFusion's capabilities. We are preparing to implement an application for a real-time view of patient information found in the paper-based chart process or that requires accessing a desktop computer. Clinicians will have real-time access to patient information from the same device that records vital signs and administers medications, labs and transfusions.

In the future, we'd like to apply CareFusion in surgical pathology to, among other things, ensure that specimens make it to the lab with no patient-identification errors. In the nursery, the system can ensure positive identification for breast milk. The potential to continue improving patient's safety and overall care is wide open.

Doris Mulder, RNC, BSN, MBA, is vice president of Beloit Memorial Hospital in Beloit, Wis.