Erayna Paquet, a nurse at Northern Michigan Hospital in the coastal town of Petoskey, knows that a computer has helped her avert at least one medical error.
Paquet was preparing to administer Prinivil, a drug used to control blood pressure. But before she did, a bedside computer alerted Paquet that she was about to give half the prescribed dose.
The result of her error may or may not have been serious. Either way, hospital officials say medication errors like that one are less common since they've given nurses someone to double check them. That someone is a computer.
Attached to the computer is a handheld scanner that nurses use to scan their own ID badge, the patient's bar-coded bracelet and the drug they're about to administer. The computer cross-checks the information to ensure that the "5 Rights" of medication administration-right time, right patient, right drug, right dose and right delivery mechanism-are all in place.
"Relying only on a human being at the very last step before a drug gets to the patient isn't good," says Susanne Larrabee, a clinical pharmacist at Northern Michigan.
Once a physician has written an order for a patient to receive medication, there are literally hundreds of chances to throw off one of the 5 Rights. Working as fast as they often must, a nurse might misplace a decimal point when she transcribes an order, or a pharmacy technician might put a medication in the wrong patient slot.
"Given the complexity in healthcare, it's remarkable we do as well as we do," says Kasey Thompson, director of the American Society of Health System Pharmacists' Center on Patient Safety. "When you consider everything that happens from the time an order is written to the time a patient receives a drug, there are between 80 and 120 steps."
It's logical enough to count only three steps: 1) physician writes order for medication, 2) pharmacy fills order for medication, and 3) medication is delivered and administered to the patient. Unfortunately it's not that simple, and each of the dozens of steps can trip things up. The vast majority of errors do not harm patients or prolong hospital stays, but some do.
Add to this a community of information technology vendors that takes on fuel for its furious sales pitches each time a new medical error report indicates that computers can help minimize mistakes. This is the highly charged atmosphere of medication errors.
Automated physician order entry is one way hospitals have addressed the problem of illegible orders and the transcription errors that can follow (See related article, p. 24). Given the time and trouble of getting doctors on board with new technology, however, other hospitals have chosen to hit the front lines and address first the medication administration phase.
One of those hospitals is Northern Michigan, where a combination of improved processes and the automated medication administration system is cutting errors while boosting the safety of patients and adding a measure of support to nurses hurrying from one task to another.
"I see this technology as an investment hospitals need to make in their ultimate missions," says Jeff Wendling, Northern Michigan's chief executive officer. "We know errors are a real issue so we ought to be using technology to help address them."
Hospitals that have been brave enough to wade through the software peddlers and navigate the media frenzy are beginning to show that the technology out there-including electronic medication management systems and robots that fill prescriptions-really can make a difference. But not many of them believe technology alone is the cure-all. From doctors and nurses to pharmacists and patient-care managers, those who have tackled medication errors in their organizations are quick to point out that technology plays a role but not a starring one.
"Many of the implementation changes that are needed are cultural, leadership and communication changes," says Donald Berwick, M.D., president and CEO of the Institute for Healthcare Improvement in Boston.
Room for error
When Valley Hospital in Ridgewood, N.J., assessed its medication administration process, the 428-bed facility discovered that it takes a staggering 313 "activity steps" to get drugs from doctor's order to patient's bloodstream.
Valley also determined that the bulk of its medication errors-59.8%-were occurring at the point of care, when nurses actually administer drug therapies.
With so many steps in the process, it's logical enough to see how any number of staffers can slip up. First the physician's order is transcribed onto a medication administration record, which is still paper-based in most hospitals. At this stage transcription errors are always a possibility. Then the pharmacist transfers the order from the record to the pharmacy system, another point at which a transcription error can be made.
Drug preparation is error-prone too: Grabbing the wrong dose off the shelf or not getting all the right additives into an intravenous solution can make a monumental medical difference. Once the drug has been prepared, it needs to reach the right floor and the right unit at the right time. Pharmacy technicians sometimes put a drug in the wrong slot or in the wrong patient room. And finally, nurses can make errors when they actually administer the drug.
Valley's internal scrutiny of its 300-step medication administration process focused attention on 18 key steps in which an error is most likely to occur. The hospital then opted to keep better track of those significant steps by implementing an electronic medication administration record. The thinking is to "take out the nonlicensed personnel and bring together and foster communication between two licensed professionals-the pharmacist and the nurse," says Michael Mutter, Valley's pharmacy manager.
A product of Franklin Lakes, N.J.-based Becton Dickinson, the electronic medication record is available to nurses on handheld devices they carry as they treat patients. Each time they prepare to administer a drug, the nurses first scan their ID tag, the patient's wristband, and the drug they are about to give. If something is off-a drug isn't scheduled to be administered yet or the dose is wrong-an alert pops up on the nurse's handheld device informing her of the error-in-waiting.
With many drugs, vital signs must be right before the medication is administered. Heart rate, blood pressure, glucose level and a variety of other indicators often affect whether and how much of a drug should be given. The BD system-like those available from other vendors-alerts the nurse to check blood pressure if she starts to administer the drug without having done so.
Officials at Valley estimate that they will reduce errors by 79% and save some $300,000 per year using the BD system with other processes that have now been standardized (See chart below).
Opportunities to do things right
On a clear day at Northern Michigan Hospital in Petoskey, patients can see the turquoise water of Lake Michigan from their rooms. Closer in, they see the mobile computer that alerts nurses when a medication is about to be administered incorrectly.
The roots of that device date back about five years, when Northern Michigan Hospital assembled a multidisciplinary committee to identify bottlenecks in the drug administration process and determine how those bottlenecks could be eliminated. Through its self-assessment, Northern Michigan discovered that it takes 65 steps to get a drug administered from the time a physician orders it.
"If it wasn't enough to scare you away, it certainly pointed out that there were plenty of opportunities to do things wrong," Wendling says. "You really have to understand the process before you can understand how or if technology can help you solve problems inherent in that process."
Northern Michigan eventually decided technology could indeed help. That's when they became a test site for Bridge Medical, a 4-year-old company that developed a medication management system it calls MedPoint.
"I think Bridge has provided a mechanism whereby the nurse has a double check," says Sherry Haneckow, Northern Michigan's director of patient-care services. "Nurses are always checking the 5 Rights; this system kind of says 'are you sure?' "
In most hospital settings, a pharmacist checks the doctor's order and a nurse verifies that the pharmacist filled the order as requested. But "there's nobody to check the nurse," says Paquet, the Northern Michigan nurse who is a chief advocate of the automation in place there.
The medication management system from Solana Beach, Calif.-based Bridge Medical improves safety but also provides peace of mind to nurses, says Tara Conti-Kalchik, a clinical nurse manager at Northern Michigan. "Nurses need to know the system they use is accurate ... no nurse wants to make that fatal error."
As a test site for Bridge Medical's first version of its automated system, 202-bed Northern Michigan is an unusual case because it experimented with different renditions of the technology as Bridge modified it based on the hospital's input. Officials are analyzing the data to determine how many errors have been averted. But anecdotally Northern Michigan knows it's preventing errors, even if monetary returns are still difficult to quantify.
"Intuitively we believe we have seen the benefit but putting some kind of dollar figure on that is really difficult," Wendling says.
The error Paquet caught would likely have gone unnoticed without the computer alert. For Northern Michigan officials, results like that are enough to justify investing in the technology.
"All you have to do is prevent a couple medication errors and the cost benefit is a null issue," says Larrabee, who is on Northern Michigan's medical error team. "From a gut level I don't even want to talk about dollars."
With Northern Michigan's figures on error reduction still forthcoming, Bridge points to other client sites where results are beginning to surface. At one hospital, an error rate of 15 per day in an eight-bed unit fell to three errors per day in a three-month period. Another site reports one error per day in a 30-bed unit, down from 55 errors per day three months earlier.
"Hospitals may not have any idea that their length of stay could be reduced or their transfer to higher areas of acuity could be reduced based on preventing the medical error that precipitated the event," says John Grotting, Bridge Medical's president and CEO.
Along with the technology, Northern Michigan and many other institutions are deploying pharmacists on patient floors to work alongside doctors and nurses (See related article, p. 33).
"Research shows that the most appropriate place for a pharmacist is not in the pharmacy but up on the floors practicing as a member of the healthcare team," says Thompson of the American Society of Health System Pharmacists.
Children's Medical Center of Dallas also is getting more out of its pharmacists. The 225-bed hospital is attacking medication administration errors from two angles, the first of which is to automate the dispensing of medications using a robot affectionately referred to as "Zippy."
Zippy has taken on the jobs of three pharmacists and four technicians, filling some 65 million doses without an error, says John Tourville, director of pharmacy. "Just freeing up pharmacists is $200,000 in savings per year," Tourville says. The robot has also lowered Children's cost per dose to $0.696 in 1999 from $0.796 in 1998 and $0.972 in 1997. In 1999 that amounted to a "cost avoidance" of approximately $654,000.
With the robot comfortably ensconced in the pharmacy, Children's is looking to the bedside and rolling out an electronic medication administration system from San Francisco-based McKesson HBOC. Similar to the ones at Valley and Northern Michigan, McKesson's AcuScan-Rx system prompts nurses before they are about to administer a medication incorrectly. Tourville says it's too early to assess how well it's working, but he does believe errors already have been prevented.
"Our goal is to be error-free," Tourville says. "We've always believed that people don't make mistakes intentionally; it's the system."
Even once an effective technology has been implemented, process improvements continue to be critical, medical error experts say. At Valley Hospital, for example, nurses now are required to verify the accuracy of the electronic medication order against the original physician order. That change stemmed from an analysis showing a 61% discrepancy rate between the original order and the electronic version.
Most of the errors that resulted from that discrepancy were not incorrect medications or doses but process problems such as a scheduling mix-up or a special instruction incorrectly explained. Having the nurses double-check the computer has helped to alleviate those errors, says Mutter, the pharmacy manager.
In addition to providing a check-and-balance mechanism, the AcuScan-Rx system Valley uses "provides a host of management reports," Mutter says. Each time a nurse administers medication, the system records information that can be tapped later to determine how and when errors still are made.
"In our mission to standardize and simplify, we want to make sure we utilize all the redundancies and safety nets that are appropriate," Mutter says.
Even with the reporting capabilities, calculating a return on investment for these technologies can be difficult. The MedPoint system usually pays for itself within a year and a half, says Grotting, Bridge Medical's president. CEOs who believe they don't have a problem might be fooling themselves.
"Hospital CEOs are coming to realize that actual errors are at least 20 to 50 times what their incident reports are suggesting," Grotting says.
"What would be the cost to this organization if we chose to do nothing about patient safety and medication errors?" Wendling asks. "Your data may tell you that you have 17 errors today. If you're comfortable with that, I'd say don't invest in the technology. If you have a doubt, you owe it to your organization to take that next step and figure out how many errors you really have."
For Northern Michigan, many of the benefits they've seen and continue to expect are nonfinancial. Officials believe, for example, that the hospital's image has improved because of its publicized patient safety initiatives.
"There's one hospital in Northern Michigan that is using technology to reduce medical errors on your behalf," Wendling says of the message his community is hearing.
