Luther Hospital and its two physician clinics are safer places to go for care in northwestern Wisconsin. During three years of intensive introspection and action, clinicians at the Eau Claire, Wis.-based healthcare system have piled up the proof:
* Adverse drug events in the hospital have declined by 60%.
* Complications related to the use of therapeutic blood thinners have been cut in half.
* Hypoglycemic events, which are serious consequences of low blood-sugar levels among patients with diabetes, are down 50%.
Behind those improvements are substantial process changes implemented after some eye-opening discoveries about sources of error and the factors that inadvertently contributed to their prevalence.
But the institution didn't have to rely on elaborate information systems or spend big sums of money to identify areas needing improvement or put the resulting remedies in place, says Roger Resar, M.D., who has spearheaded the patient-safety program.
The effort made great strides in error reduction by getting a grasp of the biggest threats to patient safety and then working with physicians and other clinicians to drive out inconsistent, confusing or downright dangerous practices in those high-risk areas, Resar says.
"It doesn't require a huge computer. What it requires is a standard way of doing it every time," he says.
That's a counterpoint to the clamor building for computerized error reporting systems and for software advances that would eliminate prescription handwriting and transcription errors.
There are good reasons to develop and adopt those advances, but in the meantime every hospital has fundamental problems with care processes that can't wait for delivery of technology, say experts in patient safety.
"There are some things that take a couple of years and some things you can do tomorrow. And you need to do both," says Terry Williams, who prescribes ways to reduce adverse medical events as vice president of the business solutions division of Eclipsys Corp., Delray Beach, Fla.
"So many places will spend countless hours and resources trying to get the best collection system (for medical errors and adverse events)," Resar says. "There's enough in your face to get started right away."
Finding places to start
Luther Hospital had a profitable and seemingly well-oiled medical machine when it started looking inward in 1997. The 310-bed hospital had combined with Eau Claire-based Midelfort Clinic and merged with Rochester, Minn.-based Mayo Foundation in 1992, and the new organization became known as Luther Midelfort-Mayo Health System. Within five years the clinic's physician staff grew to 170 from 90, a heart surgery program was established and a new outpatient building completed.
"Somewhere along the line we ended up believing that medical safety was an important thing for us to do," says Resar, who was hired part-time to direct the project. He's now a full-time change agent for patient safety.
The system's board gave a project team of clinicians $20,000 to enroll in a collaborative on reducing medical errors sponsored by the Institute for Healthcare Improvement, a Boston-based quality improvement organization.
In conjunction with participating in the national exploration of medical risks, the team conducted its own chart reviews and discussions with nurses and pharmacists at Luther Midelfort. Out of that came several improvement campaigns to track patient medications, make high-risk drugs safer and encourage a culture of safety.
Other healthcare organizations have brought in patient-safety experts to conduct extensive investigations. The consultants recommend changes based on established best practices in clinical areas as well as a growing body of research into dangers that are uncovered again and again in hospitals.
Women and Infants Hospital in Providence, R.I., underwent a complete assessment of its patient-safety preparedness last June, covering everything from leadership attitudes to error-prevention capacity on nursing units, says Mary Dowd Struck, senior vice president for patient care. The audit was conducted by Eclipsys.
"We used it as a catalyst to get people motivated in their thinking, developing some passion about medical errors," Struck says.
The facility had been accredited with commendation after its most recent survey by the Joint Commission on Accreditation of Healthcare Organizations, and that made employees think they had a great quality assurance system in place, she says.
But the audit took some wind out of their sails. "We didn't fare that well, because they were comparing us to the very best in the industry," Struck says. "If we had compared ourselves to the 'hospital next door,' we would have looked pretty good."
A patient-safety assessment process launched by another Boston-based quality think tank is concentrating on analysis of high-risk settings in the hospital.
The Institute for Health Policy, affiliated with Massachusetts General Hospital and its parent organization, Partners HealthCare System, relied on its own research as well as information from malpractice insurance companies to identify the areas it wanted to zero in on, says Jennifer Daley, M.D., an internist and director of the institute's center for health systems design and evaluation.
In partnership with Computer Sciences Corp., an El Segundo, Calif.-based information services company, the institute is parlaying its expertise into a business that evaluates and decreases the risks of hospital activities in the departments of surgery, labor and delivery, emergency and intensive care, says David Wiechers, M.D., vice president and principal of CSC's healthcare group.
Examinations of some initial client hospitals, for example, turned up problems in the handling of medication information from the emergency room to the nursing floor when a patient is admitted, Wiechers says.
If information on orders isn't transferred to an inpatient chart, a nurse has to guess whether an ordered antibiotic or other medication was given or not in the ER. A wrong guess means the medication either is missed or given twice, he says.
Glaring problems with medication
At Luther Midelfort, the examination of patient charts for medication errors revealed a ratio of 230 actual or potential errors for every 100 charts reviewed, or two to three per patient. More than half the errors were traced to incomplete communication of information on patient medications during admission, transfers from one department to another, or in the discharge process, Resar says.
An admission counselor or nurse would take patient histories and a physician would rattle off a list of orders, but there was no reconciliation of those separate activities. Consequently pre-admission medications important to a patient's health might not be ordered.
In subsequent handoffs of patient responsibility throughout the hospitalization, medications and prescription alterations were missed in the communication among caregivers, Resar says. Every time a medication was not reconciled, the project team called it an error.
The problem persisted all the way to discharge, where discussion of medications is part of the final instructions. Because of drug interactions and changes in a patient's status, some medications taken regularly before the hospital episode must be discontinued. But many patients were not told to stop taking them, so they often resumed them at home.
In response, several protocols were developed to make sure the medication tracking and ordering by nurses, pharmacists and physicians are coordinated on admission, transfer out of specialty units and at discharge. The formal process at those key stages reduced potential adverse drug events by 83% during a six-month pilot in an intermediate-care cardiac unit in 1998.
With evidence that the process did the job, the project team spread the reconciliation forms and protocols to other areas of the hospital and added slight modifications along the way.
Now patients leaving for home have a calendar of what medications to take, when to take them and what pre-hospitalization medications to discontinue.
High price of miscalculation
Other medication problems arise from mishandling dangerous concentrations of potent drugs or dealing with multiple methods of calculating a safe and therapeutic dose of strong medicine.
Luther Midelfort's patient-safety campaign included considering improvements in how it manages the threats posed by potassium chloride, insulin and the blood thinners heparin and warfarin. The improvement team worked from a list of high-risk drugs singled out by the Institute for Healthcare Improvement collaborative and the Institute for Safe Medication Practices, Warminster, Pa.
In carefully prepared strengths, potassium chloride is an electrolyte that sick people need to keep their bodies in biological balance, especially in critical-care situations. But a concentrated solution of the drug is fatal-in fact, it's used to stop the heart as part of the death penalty's lethal injection.
The institute recommends that no potassium chloride should be kept on hospital floors unless it's premixed in safe and standard concentrations. According to the institute, one of the most common causes of fatal drug errors is accidental injection of concentrated potassium chloride.
The information was enough for Luther Midelfort to store the substance away from patient-care settings unless specifically mixed and meant for a certain patient. "Potassium should not be anywhere except the pharmacy," Resar says. But he adds that there are "still thousands of hospitals that have potassium available like that." Most of the time it's because a physician wants it available immediately for any situation, he says, and the high risk and alternatives haven't been made plain.
For potent regulating drugs such as blood thinners and insulin, the solution to preventing error isn't as easy because the drugs have to be close at hand and continually monitored to adjust for blood levels in a therapeutic range.
But doctors, based on their medical training, can favor one of several different ways to calculate doses-for example, using either pounds or kilograms for a patient's weight-and different concentrations of the same drugs can be kept on nursing units.
All that variance makes it more difficult for nurses to keep track of dosing for many patients at once. Resar says physicians might use seven or eight different protocols for calculating insulin on a given care unit-not varying by much, but enough so nurses "couldn't remember who was on what."
The hospital was recording about 20 episodes of low blood sugar a week. Under the direction of physicians and pharmacists, Luther Midelfort's patient-safety team settled on one protocol for all patients with diabetes. That led to the 50% decrease in hypoglycemic events, Resar says.
Similar standardization worked for heparin and warfarin, which are used to fight blood clots but at too high a dose, the drug can cause excessive bleeding. Too low a dose could result in a stroke.
Nurses now follow a standard protocol in administering warfarin. And the health system worked to transfer warfarin management to its clinics, where it's easier for patients and less hectic for clinicians. About 90% of discharged inpatients on blood thinners get their charts and medication histories transferred to the clinic for further management.
Meanwhile, a single formula for calculating intravenous heparin has contributed to the 50% decrease in complications related to blood thinners.
At Women and Infants Hospital, a standard protocol for heparin was among the first fruits of the new patient-safety improvement initiative, Struck says. Putting management in the hands of a pharmacist transferred an unfamiliar and complicated duty to someone more familiar with the complexities, she says.
"Every doctor only uses heparin a few times a year. They weren't as familiar with it as a pharmacist who had a hundred doctors using it a few times a year."
Besides standardizing the handling of the drug, the new approach eliminated the need to involve doctors at every step of therapy, which could last two days or longer.
"Now they love it. All they have to say is, 'heparin per protocol,' " she says.
A priority for leadership
Some changes after the assessment were small but logical. Patients with an allergy, for example, got a distinctive armband to alert caregivers-documentation of allergies was in all charts and clipboards traveling with patients but not in plain view. "That was a quick fix that cost virtually nothing," Struck says.
But many of the changes resulted from keener awareness of patient safety matters at the senior leadership and board levels. In the audit, the institution fared poorly compared with the best examples in the industry. "It was good that we were compared to the best, because it exposed our vulnerability to a major medical error," she says.
For one thing, errors and near-misses weren't discussed at the board level. That not only affected a governing board's fundamental duty to assure service quality but it also affected business decisions about how to spend money and make best use of assets, Struck says. "We should be making our decisions with patient safety in mind."
Once those patient safety factors became part of the discussion, some projects rose in priority and got the green light.
The hospital pharmacy, for example, got an increase in funding enabling it to stay open 24 hours a day, seven days a week. It had been closing on weekend nights because the hospital hadn't budgeted enough to keep it open. Nurses would dispense as well as administer drugs during that time, Struck says. But that eliminated the pharmacist as an important check on physician medication orders, which put patients at risk in some cases.
In one incident, a physician prescribed an antibiotic called Augmentin for a patient who was allergic to ampicillin, thinking it was a safe alternative. But the properties of the two antibiotics were very similar, posing an allergy risk.
A pharmacist would have recognized the risk and stopped the order, but a nurse filled it directly from the doctor's prescription. "That patient had an extended hospital stay," Struck says. "She had a severe reaction."
Women and Infants Hospital also decided to allocate funds to bolster other medication activities.
Nurses had been mixing intravenous medications themselves; the hospital budgeted for purchases of pre-mixed medications.
For years the nursing staff had been asking for a better place to organize medications for delivery to patients at the bedside, Struck says. The request became a priority when evaluated against the potential for creating errors.
Medication rooms were small and not ventilated, so nurses had to leave the door open. Usually they were right behind the nursing station and prone to interruptions, noise and other distractions from the task of getting things right. "All that should be done in a quiet place," Struck says.
Gaps in information technology also were addressed with medication safety in mind. The information systems installed at Women and Infants allowed entry of orders for everything except drugs, suddenly a major shortcoming.
The heightened appreciation of error prevention provided the push needed to commit to purchasing a physician order entry application and to require doctors to use it, she says. "If we didn't have this assessment, we would have had a hard time selling this to the docs."
Not all at once
Whatever the method of assessing where to start improving medical safety, the actions involve changing the clinical care process-and that may require a go-slow approach, says Resar of Luther Midelfort.
"If you have an idea of how to standardize something, the wrong way to do it is to take this great idea, write up a protocol and take it to the governing body and say, 'We want to institute this across the organization.' It will never work," he says.
At Luther Midelfort and other healthcare systems espousing approaches taught by the Institute for Healthcare Improvement, a few physicians test new ways with a handful of patients and study how it worked. Then they revise as needed before demonstrating the benefits to their colleagues. "It's only physicians who can convince other physicians to try this stuff," Resar says.
But the convincing is essential, he adds. "So much of what we do in our hospitals is on the whim and fancy of individuals." Doctors might resist standardized guidelines as handcuffing their efforts to do their work, but Resar says physicians can't argue with what works.
"There's a combination of art and science in medicine," he says. "But what we often forget is that the art is often in how we interact with our patients rather than the scientific basis of our practice. I think physicians get these mixed up sometimes."
The medical-error prevention crescendo can help get over some of the opposition, says Daley of the Institute for Health Policy. Physicians still resist standardization efforts, "but put in the safety context, they say, 'Yeah, that's a good idea,' " she says.
Other clinicians could see the change as welcome. After years of management initiatives centered on reducing costs, hospital workers have reacted with pleasant surprise to the prospect that senior managers are committed to improving care processes, Daley says.
But chief executives might have to demonstrate that commitment persuasively to hospital staff. "There's a perception that the senior managers don't care about safety-they only care about the bottom line," she says.
As a result, hospital employees might not jump right in. "They're skeptical," Daley says. "Their first impression is that it's cost-cutting in sheep's clothing."