Consumer anxiety runs high about meds problems during hospital stays
Consumer anxiety runs high about meds problems during hospital stays
Providers say drug order and administration systems let errors slip by
One worry many patients have about going into the hospital is drug errors and adverse reactions. According to a recent study by the American Society of Health-System Pharmacists (ASHP) in Bethesda, MD, 61% fear getting the wrong medicines, while 58% fear negative interactions.
"I was surprised at the magnitude of the concern," admits Bruce Scott, RPh, MS, president of the society. (See "Top patient concerns," p. 138, and related story, "Patients’ drug worries spur desire for information," p. 140.)
It’s true that the public is hearing more than ever about medication and drug mix-ups, so it wouldn’t hurt for health care professionals to speak up about the relatively small error ratio to the growing volume of drugs used, Scott says. Still, he adds, each mistake is one too many.
Most of the problems are caused by human error — not lack of knowledge. And contrary to popular belief, Scott says, he has yet to find solid data to confirm that short staffing causes errors.
"It’s usually something in the system that prevented the error from being caught. So, we have to get all the people in the process involved in identifying where our systems break down," he says.
Again, it’s the system
When you get people to share "intimate knowledge" of their work areas, they can tell you exactly where the problems are, notes Sharon Kleefield, PhD, director of Quality Management Services at Harvard Medical International in Boston. In an instant, a nurse can describe where drug errors are waiting to happen due to workflow problems on a unit. "Systems are designed to produce exactly the results they produce," she says. "Computerized order entry alone can’t prevent drug errors. You have to know where the other problems in the system are."
One general principle has been shown to improve the identification and reduction of drug errors, according to Martha Vander Vliet, RN, researcher at the Clinical Trials Center of the Brigham and Women’s Hospital in Boston. "Organizations that handle mistakes confidentially get better results. Over time, we see people come forward in those organizations and own their mistakes."
By the same token, if people get nothing but a reprimand and business goes on as usual, it discourages forthrightness. Vander Vliet illustrates that point with a personal experience: "One time I made an error. When I admitted it, I got a reprimand and it went into my record. But when I explained how the system could be changed to prevent a repeat, nothing came of it. It was discouraging."
"When people make mistakes, it eats at them," she says. "If the system encourages them to talk about what they could do differently, the solutions that come out are incredible."
For such openness to thrive, however — especially among physicians — you need the blessing of top administrative and medical management, explains David W. Bates, MD, chief of the division of general medicine at Boston’s Brigham and Women’s Hospital and associate professor of medicine at Harvard Medical School.
Creating a culture of improvement
In this better-than-average environment we’re describing, the dialogue about safer pharmaceutical care is continuous. It doesn’t pop up just when someone makes a mistake. "Everybody owns quality. You have to organize it so that everybody plays an active role in it. It must be interdisciplinary," Kleefield notes. Then, it’s natural for clinicians to approach each other in a benign way to work out mistakes in dosage or other potential problems.
That said, however, if an individual commits a gross error where preventive safeguards are in place, "it has to be handled harshly," she adds. Such an error might involve a computerized order placed in spite of warnings about the recipient’s allergies.
Nevertheless, experts maintain it takes at least two to three years to build such a culture of improvement. Meanwhile, better drug ordering and administration processes can be put into place. There are two type of approaches QI professionals can take to tackle the problem:
1.High-tech approaches.
The safest systems have computerized order entry, Bates says. In one of his numerous research projects, order entry cut nonintercepted, serious medication errors by 55%, from 10.7 to 4.86 events per 1,000 patient days.1 "Computer order entry by physicians makes it safer to prescribe because they can check for potential drug interactions and look up the patient’s allergies. Even if it’s not feasible for an organization in the near future, it’s a good thing to think about it eventually."
Scott adds bar-code scanners to the list of error-prevention technologies. At the bedside, nurses scan the bar codes on medications to confirm that they match with identification codes on individual patient bracelets.
2.Low-tech approaches.
"You don’t have to wait for that $1 million computer. What we’ve learned from places that have the benefit of sophisticated information systems can be put to use anywhere," Kleefield contends. For example, she helped design a nursing "crib sheet" of conversion tables for drug dosage by patient’s weight and other factors.
Vander Vliet’s research1 shows that standardized mixtures of IV fluids complement computer order entry as a powerful safety intervention. Almost equally effective are labels matching IV tubes with the right bags and pumps. "Sometimes you’ll have 10 IVs for one patient and, when you’re busy, it’s easy to confuse them. Hospitals could make this a standard of care rather than call it good nursing skills.’ It sounds simple," she says, "but that’s the beauty of so many safety interventions. They’re simple, but we don’t do them consistently."
Critical pathways, Kleefield says, help all parties comprehend the whole picture of a care episode. They give the physician, nurses, pharmacists, dietitian, and social worker a framework in which to plan patient care events. For example, an inappropriate medication appears on day two of an uncomplicated hysterectomy — the nurse might catch it at the bedside. When the physicians participate in designing critical care pathways, it’s easier to approach them about questionable orders.
Patients and their families are potentially valuable allies in QI and medication safety, Kleefield points out. When patients are admitted, show them the critical pathway for their hospital stay, she urges. "If they know, for example, that they will get up and walk the day after surgery, and they should receive a certain medication, they’ll watch for those things to happen. It designs and reinforces their expectations."
Drawing from ASHP survey feedback, Scott suggests that patients want to talk to the pharmacist. The study reveals that 76% of the respondents would find it reassuring to speak with a pharmacist about their medication concerns. However, a 1998 survey by ASHP shows that consumers hardly realize pharmacists are available as inpatient providers. A mere 1% named pharmacists as members of the health care team, and only 12% said they met with pharmacists while hospitalized. Organizations could make it a point to offer them the option instead of waiting until they ask, Scott says.
"Because hospitals are so crazy these days, it’s good to get [patients] involved as some of the gatekeepers of quality," Kleefield adds. As they follow the process and ask questions, they help staff catch errors before they happen. Patients and families find such involvement comforting and reassuring. "For patients, the most critical predictor of satisfaction isn’t the food — it’s the inclusion in decision making." (For insight into the present state of public trust and confidence in health care, see "Health Care’s Public Image Has Room for Improvement," p. 139.)
Health Care's Public Image Has Room for Improvement | |
Trust and satisfaction in the health care system are a bit tarnished, according to findings by the National Research Corp. (NRC) in Lincoln, NE. Public perceptions, as well as reactions from recent users of hospital services, suggest that the quality mission is far from accomplished. | |
Note: these data are visit satisfaction ratings of completely satisfied and very satisfied with overall quality of care and services. | |
Total utilization/episode | 68.6% |
Hospital inpatient stay | 70.3% |
Hospital emergency room | 56.6% |
Outpatient/same-day surgery | 78.6% |
Outpatient testing/X-rays | 72.0% |
Source: 1999 NRC Health Care Market Guide, National Research Corp., Lincoln, NE. |
1999 Trust and Confidence in Health Care Survey | |||||
Based on responses from a cross-section of U.S. households | |||||
Trust and confidence in hospitals | |||||
Ratings | 5 (high) | 4 | 3 | 2 | 1 (low) |
1998 | 19.6% | 36.4% | 33.3% | 7.2% | 3.6% |
1999 | 13.0% | 40.1% | 37.8% | 6.7% | 2.3% |
Trust and confidence in physicians | |||||
Ratings | 5 (high) | 4 | 3 | 2 | 1 (low) |
1998 | 26.8% | 42.9% | 24.9% | 3.8% | 1.6% |
1999 | 18.3% | 45.7% | 29.5% | 4.9% | 1.6% |
Interest in making a profit vs. providing quality care, hospitals | |||||
Making a profit | Providing quality care | Both equally | |||
1998 | 37.5% |
18.3% |
44.2% |
||
1999 | 37.9% |
16.9% |
45.2% |
||
Interest in making a profit vs. providing quality care, physicians | |||||
Making a profit | Providing quality care | Both equally | |||
1998 | 18.3% |
34.1% |
47.6% |
||
1999 | 22.6% |
28.7% |
48.6% |
||
Source: National Research Corp., Lincoln, NE. |
Reference
1. Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 1998; 280:1,311-1,316.
Need More Information?
For information on drug prescription and administration safety, contact:
o Bruce Scott, RPh, MS, President, American Society of Health-System Pharmacists, 7272 Wisconsin Ave., Bethesda, MD 20814. Telephone: (301) 657-3000. Fax: (301) 652-8278. Web site: www.ashp.org.
o Sharon Kleefield, PhD, Director of Quality Management Services, Harvard Medical International, Boston. E-mail contacts only: [email protected].
o Martha Vander Vliet, RN, Researcher, Clinical Trials Center, A-4, Brigham & Women’s Hospital, 75 Francis St., Boston, MA 02115.
For information on data regarding patient satisfaction and general concerns with health care delivery, contact:
o National Research Corp., Gold’s Galleria, 1033 O St., Lincoln, NE 68508. Telephone: (402) 475-2525. Fax: (402) 475-9061. Web site: www.nationalresearch.com.
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