The Enterprise Take on Patient Safety

Despite Herculean efforts on the part of clinical staffs, medical errors still plague most hospitals. Mismatched blood types, surgical removal of healthy limbs and adverse drug reactions grab the headlines and perpetuate providers’ fears of multimillion dollar malpractice suits and consumers’ fears of permanent damage.

The gravity of this problem 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 per year were caused by medical errors. The price tag for these errors was estimated at $17 billion and $29 billion.

A more recent study released by The Commonwealth Fund in 2002 found that an estimated 22.8 million people have experienced some kind of medical error, either personally or in their families.

When POC Isn’t Enough
The IOM study stated that half of medical error-related fatalities could be prevented if systems were in place to detect errors before they occur. “That study affected the entire industry,” says Eric Saff, chief information officer at John Muir/Mt. Diablo Health System in Walnut Creek, Calif. “There was a direct correlation between that report and investments in IT.” The IOM study also pointed out the need to make clinical information available to all practitioners treating a patient, so everyone knows what has been done and when.

While much of the healthcare industry’s response to medical errors has focused on bringing more clinical information to the point of care via information technology, there are some for whom even that isn’t enough. Nancy Pratt, R.N., M.S.N., senior vice president of clinical effectiveness at Sharp Healthcare in San Diego, believes that information from across the enterprise must be pushed to where it’s needed. It’s not enough to have that information just at the patient’s bedside, she says.

Pratt realized that patient safety is crucial at every point in the patient care process. She was instrumental in upgrading Sharp Healthcare’s clinical information system by installing customizable “triggers” or alerts that could provide clinicians with automatic warnings when a patient’s vital signs indicate an oncoming crisis or physical deterioration.

In fact, many of the sophisticated alerts now available in the August 2004 release of Essentris OnWatch by San Diego-based CliniComp Intl., are due to Pratt’s desire for an extensive set of patient safety triggers. About two years ago, she attended an Agency for Healthcare Research and Quality (AHRQ) presentation and was most impressed by the 25 to 30 patient safety triggers spotlighted in the presentation.

Pratt contacted the CEO of CliniComp, for whom she had worked as vice president of clinical programs and services until 1999. She sent the AHRQ list of triggers to CliniComp and asked if an automated system of real-time patient safety triggers could be designed for Sharp.

Enterprise Surveillance
Within 60 days, she had what she wanted: CliniComp developed an application that gave Pratt 38 triggers. “These are intelligent alerts,” she says. “We have lots of data available at the bedside for the clinician, but what this system of alerts gave us was across-the-hospital surveillance.” Running on the backend data repository of Sharp’s CIS, the application monitors on a second-by-second basis a range of indicators, or triggers, in multiple categories that would indicate which patients are likely to be at greater risk and might require early intervention. Configurable to meet specific needs, these triggers might include spikes in temperature, hemodynamic instability, potential adverse drug reactions or dangerous blood glucose levels.

“We have lots of data available at the bedside for the clinician, but what this system of alerts gave us was across-the-hospital surveillance.”

—Nancy Pratt, R.N., M.S.N.
Sharp Healthcare

If a trigger has been reached, an asterisk appears in the OnWatch window indicating the patient’s name, location and the trigger that was reached. The system does not have an audible alarm, so clinicians must be attentive. But as Pratt notes, “It’s not an alert system without people.”

Once the triggers were configured to the right levels, Pratt then began to wonder who would use them. “I started showing the system to different departments, and the group that was fastest to the starting line was diabetes services,” she says. The fact that Sharp had a huge diabetes initiative under way also gave Pratt a ready-made baseline.

“Clinicians saw technology as something apart from patients. … Philosophically, we had to get them to see that all of these tools are part of patient care.”

—DeLynn Peltz, R.N.,
John Muir/Mt. Diablo Health System

Because a major thrust of the diabetes initiative has been to tightly manage patients’ blood sugar levels, Pratt was impressed with the results gained from using OnWatch. In just more than six months, blood sugar levels for admitted patients dropped from a mean blood glucose value of 171.6 and a standard deviation of 72.9 to a mean of 158.2 with a standard deviation of 63. This means that blood sugar levels were reduced by 7.8 percent solely as a result of tighter controls, she says.

While reducing these levels was important, Pratt says there’s more at stake here. “We’re not just looking at levels. We want to see the trends.”

Word Spreads Fast
After the initial roll-out for diabetes services, Pratt says nurse managers began to show an interest in OnWatch. But because the original version was browser-based and password protected, Pratt says she got a flood of requests from nurse managers for passwords. The next group to demonstrate interest in the automatic triggers was the pharmacists, Pratt says. “Ideally, you want to know before you give a reversal agent that the problem is there,” she explains.

Following nurse managers’ and pharmacists’ acceptance, the system just “took off like wildfire,” says Pratt. The intensive care unit, step-down units, and medical and surgical units all saw the value in these automatic, real-time triggers. As an integrated, regional healthcare delivery system that includes four acute-care hospitals with 1,571 acute-care beds, three specialty hospitals, including a women’s hospital and psychiatric center, and three medical groups, Sharp Healthcare is currently running the Essentris OnWatch application on its network in three of the four acute-care hospitals. Now, any clinician directly involved in patient care has access to this application from any desktop on the network.

Time Well Spent
One of the most eye-opening findings in the IOM study was that medication errors alone account for about 7,000 deaths annually. While many hospitals waited until after the IOM report was published before turning the corner on patient safety, John Muir/Mt. Diablo Health System already had begun to put into place technological safeguards. “A decade ago, we realized we could affect patient safety through IT,” Saff says. “Before, information systems were a source of truth, but not the source of truth.”

DeLynn Peltz, R.N., who is director of clinical informatics, agrees that patient safety has always been a major concern at John Muir/Mt. Diablo. “Because we started working on patient safety initiatives before the IOM study, nothing at our organization stopped so we could optimize patient safety,” she says. “We have a complete Cisco wireless network. We have live biometrics and PACS. We also have enterprise numbering on all patients; each patient has the same identification number no matter where they entered the system.”

“There was a direct correlation between [the IOM] report and investments in IT.”

—Eric Saff
John Muir/Mt. Diablo Health System

The organization began using medication bar coding in 1997 and had been employing clinical documentation at the point of care since 1996. A true McKesson shop, the 321-bed John Muir Medical Center uses Horizon Clinical Documentation, Horizon Meds and IVs and STAR Pharmacy. In March, it went live with AdminRX on both full-screen computers and hand-helds. The hospital also switched from mobile to hand-held scanners.

Hired as a consultant in 1997, Peltz admits she faced a number of challenges integrating the relatively new bar-coding technology into the patient care process at John Muir. “Clinicians saw technology as something apart from patients,” she says. “They saw it as taking away from patient care. Philosophically, we had to get them to see that all of these tools are part of patient care.”

Yet Saff points out that bar-coding systems were shown to provide an extra layer of safeguards. “With the system in place, we can catch more. We have information we didn’t have before, so we can look at the areas where errors can occur.”

IT Supports Professional Goals
One of the biggest hurdles Peltz faced when she first came on board was dispelling the belief among nurses that bar coding at the bedside was going to slow them down. “When you use information technology to positively ID a patient, yes, it always takes more time than administering medications the old-fashioned way. But that process leads to errors,” she says.

Peltz was able to show nurses that even if it took longer to medicate patients, they could recapture that time by using another form of IT. Not having to copy orders was one example. Peltz demonstrated how electronic clinical documentation could save them a few minutes here and there, so nurses could emerge ahead of the game time wise. She also capitalized on the professionalism and value systems that nurses, in general, maintain. If one of their treatment goals was to never 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 that goal.

Eventually, the nursing staff became her steadfast allies in adopting and configuring this technology. “We worked side-by-side with the nurses,” Peltz says. By assembling a multidisciplinary team that included nurses, pharmacists, analysts and other staff members, the clinicians were able to examine the entire medication loop and identify where the risk points were.

Because the John Muir/Mt. Diablo Health System was a pioneer and because earlier technology was not as sophisticated as current technology, the organization found that medications were being delivered that the nurses couldn’t read, and that led to an upgrade in readers. “Bar coding is not a one-size-fits-all,” says Peltz. “Depending on the bar-code reader, the distance to read and the angle with which the reader is held, there are subtle differences.”

Nurses also pointed out that cart-mounted scanners were difficult to navigate in small rooms. “We still have those mobile devices, but hand-helds are much more flexible,” says Saff.

Workflow was another area that needed review. “We customized workflow by department because the screens are different,” Peltz says. “We had a committee of nurses, and they taught us their workflow.” As part of this process, nurse analysts were able to modify documentation screen flows and content to maximize their usability among the nurses. The hospital also began generating weekly reports using Horizon Clinical Query to determine existing performance and outcomes. “We were charged by the board to have evidence,” Saff explains. “Query allows us to do that.”

Unparalleled Results
Still being generated on a weekly basis, these reports show the bar-coding frequency by medication, unit and nurse, as well as medication errors and error alert overrides. “We keep track of their compliance,” says Peltz. “We audit that and a nurse’s reaction to an error message.”

While these reports are sent to nursing directors and the administration, summaries of the report also are 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.”

John Muir/Mt. Diablo Health System’s focus on reducing medication errors has yielded some spectacular results. According to Saff:

While these results are impressive, they actually reflect the organization’s total commitment to patient safety and the role that information technology can play in improving patient care. This fall, John Muir Medical Center will install robotic dispensing machines in its pharmacy as a way 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 yields benefits.

Richard R. Rogoski is a free-lance writer and contributing editor to HMT. Contact him at rogoski@aol.com