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Life Saving Initiatives
Patient Safety Imperative
The gravity of medical errors first came to national attention in 1999 when the Institute of Medicine (IOM) published a study indicating that between 44,000 and 98,000 U.S. deaths a year were caused by mismatched blood types, surgical removal of healthy limbs, and adverse drug reactions - to name a few glaring examples. One of the most eye-opening findings was that medication errors alone accounted for approximately 7,000 deaths a year.
Proactive Practice
While many hospitals waited until after the IOM report was published before turning the corner on patient safety, John Muir Health had already established technological safeguards. "A decade ago, we realized we could affect patient safety through IT," states Eric Saff, chief information officer at John Muir Health. "In 1996, we began to improve patient care by employing clinical documentation at the point of care and introducing bar coding medicines at the bedside in 1997. We have a complete Cisco wireless network, employ live biometrics and PACs, and use enterprise numbering on all patients."
Money Well Spent
"The IOM study affected the entire industry," says Saff. "There was a direct correlation between that report and the investments in IT." In 2001, the Health System implemented a $40 million initiative to use advanced technology to improve patient safety and support clinical decision-making. The enhanced technology and sophisticated processes maximized error-proof medication delivery to patients, and the results showed a significant decrease in situations that could have resulted in medication errors.
On Track
Weekly reports show bar-coding frequency by medication, unit, and nurse, as well as medication errors and error alert overrides. "We audit users' compliance and reactions to an error message," says DeLynn Peltz, RN, director of clinical informatics. "While these reports are sent to nursing directors and the administration, summaries are also sent to the performance improvement committee and the board." Although the reports are used in annual employee performance reviews, Saff stresses that the organization has a "blame-free environment."
Return on Investment
Our focus on reducing medication errors has yielded some spectacular results:
The presence of readable bar codes on unit-dose medications dispensed to the nursing units increased from 8 percent in 2001 to more than 99 percent as of November 2004. The readability of the bar codes has improved to nearly 100 percent, ensuring that clinicians are able to make full use of the system's safety features.
Staff compliance with these procedures improved from 80 percent in the first quarter of 2001 to 94 percent house-wide, and up to 96 percent for adult medical/surgical and critical care units by the third quarter of 2004. More than 75,000 medication orders are administered per month.
The frequency with which staff overrides alerts for wrong drug, dose, or route fell from nearly 50 percent in the second quarter of 2002, to less than 8.6 percent in the third quarter of 2004.
Med-error and near-miss reporting has increased by 39 percent between 2001 and 2004, while the percentage of those errors causing patient harm has decreased by 33 percent. In addition, the percentage of errors causing harm has remained below national averages since 2003.
The Challenges
Faced with integrating the relatively new bar-coding technology into the patient care process, clinicians saw technology as something apart from patients. They saw it taking away from patient care. Philosophically, we had to get them to see that all of these tools are part of patient care.
Dispelling the belief among nurses that bar coding at the bedside would slow them down was another hurdle. We were able to show them that even if it took longer to medicate patients, nurses could recapture that time by using another form of IT. Not having to copy orders was one example - electronic clinical documentation could save time. We capitalized on the professionalism and value systems that nurses maintain. If one of their treatment goals was never to make a mistake in administering patient medications, then it was worth taking a little extra time to learn and use the technology that would enable them to achieve their goal.
Ask the Experts
We customized workflow by department because the screens are different. A committee of nurses explained what they needed. Nurse analysts modified documentation screen flows and content to maximize usability. The hospital also generated weekly reports using Horizon Clinical Query to determine existing performance and outcomes, and provided evidence.
The Future
A true McKesson shop, the 324-bed John Muir Medical Center uses Horizon Clinical documentation, Horizon Meds and IVs, and STAR Pharmacy. In March 2005, we went live with AdminRX on both full-screen and hand-held computers. The hospital also switched from mobile to hand-held scanners. While results to date are impressive, they actually represent the organization's total commitment to patient safety and the role that IT can play in improving patient care. This fall, John Muir Medical Center will install robotic dispensing machines in its pharmacy to better utilize pharmacists' time. "We want to move the pharmacists onto the floor as part of the care team," says Peltz. "There's a new role for IT," she adds. "We see ourselves as advocates for clinicians. This organization has put itself in IT's hands, and that represents a huge philosophical difference from many other organizations." Clearly, it is a difference that is worthwhile.