The Solutions for Patient Safety initiative Improves Healthcare In Ohio

As reported on Patient Safety & Quality Healthcare Website

A collaborative effort among  healthcare providers and leaders to make the state of Ohio, one of the safest places in the country for healthcare has led to more than $12.8 million in healthcare savings. This effort has also led to more than nine hundred fewer patient days spent in the hospital and nearly 3,600 fewer adverse drug events and infections in children.

This effort is called, The Solutions for Patient Safety initiative.The goal of the partnership is to improve quality and reduce costs of healthcare statewide. It was launched in January 2009 and funded with a $1.5 million investment from the Cardinal Health Foundation. In addition this partnership includes the Ohio Business Roundtable, the Central Ohio Hospital Council, the Ohio Hospital Association, the Ohio Children’s Hospital Association and twenty five hospitals throughout the state.

“Cardinal Health is proud to be a founding sponsor and ongoing partner in this groundbreaking initiative that has and will continue to save lives – not only throughout Ohio, but across the nation,” said George S. Barrett, chairman and CEO, Cardinal Health. “The impressive results of the Solutions for Patient Safety initiative prove that true collaboration among healthcare leaders and clinicians can create meaningful transformation in patient care.”

Ohio’s eight children’s hospitals and 17 Central Ohio hospitals worked to implement specific programs to reduce healthcare-associated infections (HAIs) and medication errors. Through their work, the hospitals identified data collection protocols and best practice processes that were shared among the institutions and will also be shared with interested outside organizations in Ohio and nationwide.

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Medicine Reconciliation Impacts Patient Safety

By Donna Horn, BSc(Pharm); Michael J. Gaunt, PharmD; Allen J. Vaida, BSc(Pharm), PharmD

In any given week, 4 out of every 5 U.S. adults will use prescription medicines, over-the-counter (OTC) drugs, or dietary supplements (Aspden et al., 2006). Poor communication of a patient’s medication-use history between community practitioners and emergency department personnel contributes to many adverse drug events (ADEs) and can be a potential source of harm to patients (Pippins et al., 2008). For 2004 and 2005, it is estimated that more than 700,000 patients each year were treated in U.S. emergency departments for ADEs (Budnitz et al., 2006).

One out of every 6 of these patients required further care (e.g., hospital admission, transfer to another facility, and emergency department observation admission). During an 11-month period from September 2004 through July 2005, more than 2,000 medication error reports involving a reconciliation issue were submitted to MEDMARX (USP, Rockville, MD) (Santell, 2006). Approximately 22% of these reconciliation-related errors occurred during the hospital admission process. Cornish et al. (2005) found that roughly 54% (81 of 151) patients had at least one unintended medication discrepancy at the time of hospital admission. In another study, discrepancies among documented regimens from different sites of care were found to be highly prevalent, with up to 67% of inpatients in the study having at least one error in their medication history at the time of hospital admission (Pippins et al., 2008). Other studies support that at least 50% of all patients have had at least one unintentional medication discrepancy (Gleason et al., 2004; Lau et al., 2000).

Medication reconciliation is a process that aims to improve patient safety and reduce the risk of medical error by ensuring that healthcare providers have an up-to-date list of the medications a patient is taking. A recent study of hospitalists involved in design and implementation of medication reconciliation processes felt that medication reconciliation would likely have a positive impact on patient safety (Clay et al, 2008). This information, which can reduce therapeutic duplication and adverse drug interactions, must include the drug name, dose, and frequency. ADEs are frequent and often preventable patient safety incidents. Patients are most at risk for ADEs during transitions in care (hand-offs) across settings, services, providers, or levels of care, including community pharmacy services. The goal of “medication reconciliation” is to prevent these ADEs. 

The medication reconciliation process has been demonstrated to be a powerful method for reducing ADEs and medication errors (Provonost et al., 2003; Rozich et al., 2004). However, one important aspect of medication reconciliation’s success depends on emergency department (ED) and other hospital personnel accessing the patient’s most up-to-date medication history from the outpatient setting. To do this, effective communication between community pharmacies and EDs is critical.

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Look A-Like Medication Names Effect Patient Safety

Previously published in Patient Safety & Quality Healthcare

William N. Kelly, PharmD, FISPE; Matthew Grissinger, RPh, FISMP, FASCP; and Marjorie Shaw Phillips, MS, RPh, FASHP

Medication errors can result in significant morbidity and mortality and more costly care. Look-alike drug names that contribute to wrong drug errors are pervasive. These errors happen in various ways; for example:

Prophylactic antibiotic coverage with penicillin 500mg oral tablets four times a day was ordered for a 43-year woman in intensive care with severe mitral and tricuspid valve regurgitation and an incidental jaw fracture who was scheduled for a surgical valve repair. On the second day of antibiotic therapy, a nurse compared the drug she was to administer with the medication administration record and discovered the patient was receiving penicillamine instead of penicillin. Further evaluation revealed the staff member who entered the order into the pharmacy computer system typed in “PENIC” and had received a drop-down box that displayed all the formulations starting with “PENIC.” The pharmacist entering the order unintentionally selected penicillamine instead of penicillin (Flynn, 2006).

A 40-year-old woman with bipolar disorder (on trazodone) received handwritten prescriptions for Zyrtec® and Atarax® to treat a new episode of urticaria. The pharmacist dispensed Zyprexa® instead of Zyrtec. It was not until a 2-week follow-up appointment that the error was identified (Cohen, 2003).

Epinephrine and ephedrine were available on override in adjacent sections of an automated dispensing cabinet drawer. When a physician requested a dose of ephedrine for a patient in labor, a nurse hurriedly drew up a dose of epinephrine and handed it to the primary nurse, who administered the dose. The patient experienced chest pain and a period of hypertension before the baby was born, however, there were no long term effects for the mother or newborn (ISMP Medication Error Reporting System, n.d.).

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First, Protect the Patient from Harm-Applying Adult Learning Principles to Patient Safety

Published in the July/August Issue of Patient Safety & Quality Healthcare
By Barbara Duffy, RN, BS Ed, MPH, CPHQ, LHRM

“First, do no harm.”

Today, unlike in the time of Hippocrates, evidence of harm may not become immediately obvious during healthcare interventions. For example, a lapse in attention while inserting a central line may result in a blood stream infection that becomes apparent days later. A wrong site surgery may go unnoticed until after the effects of anesthesia subside. An incorrect dosage of medication may not be recognized until an adverse drug event occurs.

During the past decade, there has been no shortage of statistics showing the hazards awaiting those seeking healthcare services. As a consequence, hospitals have undertaken an abundance of initiatives to prevent harm among patients. Despite massive attempts to educate healthcare staff regarding patient safety measures, the Agency for Healthcare Research and Quality (AHRQ, 2007) reports patient safety is improving at a disappointing 1% per year.

Hospitals, anxious to meet accreditation standards, measure staff knowledge of the National Patient Safety Goals set forth by The Joint Commission since 2003. However, the AHRQ evidence suggests being knowledgeable of threats to patient safety is not sufficient to change the behavior in ways that are necessary to improve patient outcomes on a large scale. Higher levels of cognition are required by healthcare workers to comprehensively reduce medical error and effect culture change. To accomplish this, adult learning principles are coupled with higher levels of the cognitive domain and applied to patient safety situations in an effort to prevent error throughout the clinical setting. In other words healthcare workers learn how to first, protect the patient from harm.

Medical Errors in Healthcare

Medical errors have produced tragically high numbers of deaths and injuries to patients. An industry dedicated to protecting lives has become the eighth leading cause of death (Sexton, Thomas, & Helmreich, 2000; Vicente, 2002). As Table 1 shows, the magnitude of harm to human life is considerable. While most research has been performed in the in-patient setting, there is no reason to believe patient harm does not occur with disturbing frequency in other settings such as private practice, skilled nursing facilities, pharmacies, and ambulatory surgical centers. (Aspden, Wolcott, Bootman, & Cronenwett, 2007; WHO, 2007a).

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Consumers Advancing Patient Safety Endorses White Paper on Reducing Medication Errors

Medication errors are one of the most widespread and preventable causes of harm in modern healthcare. Now Consumers Advancing Patient Safety (CAPS) and more than a dozen other leaders in the patient safety field are teaming up to promote best practices to prevent them.

Together with Joint Commission, the Society of Hospital Medicine and other leaders in hospital healthcare, CAPS has endorsed a new white paper that gives hospitals practical recommendations for implementing system-wide medication reconciliation programs.

The white paper, Making Inpatient Medication Reconciliation Patient Centered, Clinically Relevant, and Implementable: A Consensus Statement on Key Principles and Necessary First Steps.

It will also be published in the Journal of Hospital Medicine.

“Medication reconciliation can be a complex challenge to tackle,” says Mitchell Dvorak, CAPS executive director. “The new white paper gives clinicians, quality and patient safety personnel, and regulatory agencies practical steps for reducing medication-related preventable harm.”

The white paper identifies ten key areas for improvement in medication reconciliation and provides actionable “first steps” for addressing each.

It closes with “Patient safety and patient/family-centered care must be the principal drivers in the development of medication reconciliation implementation systems,” a sentiment echoed by Dvorak, and emphasizes that medication reconciliation must be seen as a patient safety issue, not simply about accreditation. “Ultimately, this is about using a team-based approach to provide the best possible care to every hospitalized patient.”

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CAPS Joins the Fight Against Medication Errors

Chicago, Illinois, October 15, 2010—Medication errors are one of the most widespread and preventable causes of harm in modern healthcare. Now Consumers Advancing Patient Safety (CAPS) and more than a dozen other leaders in the field are teaming up to promote best practices to prevent them.

Together with Joint Commission, the Society of Hospital Medicine and other leaders in hospital healthcare, CAPS has endorsed a new white paper that gives hospitals practical recommendations for implementing system-wide medication reconciliation programs.

The white paper, Making Inpatient Medication Reconciliation Patient Centered, Clinically Relevant, and Implementable: A Consensus Statement on Key Principles and Necessary First Steps, is available via the following link.

It will also be published in the Journal of Hospital Medicine.

“Medication reconciliation can be a complex challenge to tackle,” says Mitchell Dvorak, CAPS executive director. “The new white paper gives clinicians, quality and safety personnel, and regulatory agencies practical steps for reducing medication-related preventable harm.”

To read more please visit Patient Safety & Quality Healthcare