Advances in Patient Safety

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.

Patient Safety Initiatives in Maryland and Oregon are Showing Signs of Success

October 26, 2011 | Lebowitz & Mzhen

Pharmacy and medication errors in hospitals and elsewhere in the health care system create substantial risks to patients, along with errors in diagnosis and treatment, equipment problems, and others. State governments often work to promote and improve protection of patient safety in health care. Oregon, as an example, has taken a step towards improving patient safety by encouraging self-monitoring and reporting by hospitals, doctors, and pharmacies statewide. The Oregon Legislature passed a bill in 2003 that created the Oregon Patient Safety Commission, a collaboration between the health care industry and state agencies to prevent medical errors. The state estimates that, last year, at least 34 deaths throughout Oregon resulted from medical errors. The program encourages the submission of detailed reports on medical errors to the Commission, which compiles the data and keeps track of statistics and trends.

Oregon has 58 community hospitals, and all of them have agree to submit reports. Most of the state’s hospitals have been reporting since the program started in 2007, and only two hospitals were still holding out as of last year. According to the Oregon Association of Hospitals and Health Systems, hospitals are reporting errors at a rate to similar to that in states that mandate reporting. The system is far from perfect, though. Because of its voluntary nature, hospitals do not always provide patients with notifications of errors, even if they report those errors to the state. Hospitals also do not report every error known to have occurred.

Pharmacies and surgical centers in Oregon have some catching up to do. According to an investigation by the Oregonian newspaper, the state’s pharmacy board receives about 600 complaints per year, but the Commission only received six error reports from pharmacies between the fall of 2008 and the summer of 2011. About half of Oregon’s licensed surgical centers have agreed to participate with the Commission, and of those who have agreed, only two-thirds actually reported anything in the past year.

Pharmacists Compete With Pill-Packing Robots for Patient Safety

October 11, 2011 | Lebowitz & Mzhen

A new machine at the University of California at San Francisco may permanently change the way pharmacies operate, hopefully to the benefit of patient safety. The machine is a “robot pharmacist” named PillPick, and it does much of the work ordinarily performed by pharmacists and pharmacy technicians. So far, as shown in this video, it has been able to do the work with a far lower error rate than human pharmacists.

PillPick cost around $7 million to install, which is less than the amount UCSF spends in a year on pharmacist salaries. People must periodically stock the machine with medications, but PillPick is largely autonomous after that. Medications are stored in bins and marked with bar codes. The machine identifies the correct medication and uses a suction-powered arm to remove pills from bins. Its programming allows it to recognize when its arm has failed to pick up a pill or has picked up too many. It sorts the correct number of pills to fill a prescription and applies labels with the identifying prescription information. At full capacity, it can dispense more than 10,000 medication doses in a day. UCSF reports that PillPick has freed its pharmacists to work in other areas of the hospital, such as managing IV medications and patient drug treatments. In over 350,000 doses, it apparently has not made any errors. A pharmacy robot suitable for retail use costs around $200,000, making it a tempting investment for many pharmacies.

The role of the pharmacist has changed considerably as technology has advanced. With computers and newer systems of packing and distributing medications, pharmacists now spend much of their time supervising the dispensing of pre-packaged medications rather than actually preparing medicines. Machines like PillPick are in many ways a continuation of these changes, with the goals of improving efficiency, cutting costs, and reducing the risks of human error in dispensing medications. Human error is the single largest factor in pharmacy errors, occurring in as much as two percent of all prescriptions nationwide.

Unfortunately, it is impossible to ensure that pharmacy errors never occur, whether a pharmacy is managed by a human or robotic pharmacist. The legal requirement that a licensed pharmacist dispense medication is sometimes the only reason human pharmacists are directly involved in the process. The presence of a licensed pharmacist lends a sense of professionalism to a pharmacy, but more important, it gives the appearance of accountability. In the event of an error, someone is in charge to handle the problem or take the liability. The use of robotic pharmacists creates interesting legal questions relating to liability for errors. Where a human pharmacist’s error creates an issue of professional negligence or malpractice, a machine replaces it with issues of proper operation or maintenance as well as product defects.