Building a Safety Net

It’s not the threat of lawsuits as much as a desire to deliver better healthcare that is driving much of today’s efforts to improve patient safety.

Whether it’s reducing medication errors or monitoring the onset of symptoms to facilitate treatment protocols, clinicians are tapping into huge databases for their answers. But, to achieve the desired results, hospitals need to invest in newer clinical systems that feature medication reference databases or find new uses for existing databases, like those that are integral parts of electronic medical records.

Medication Automation
When it comes to reducing medication errors, a number of vendors have automated the entire medication administration process—from the transmission of orders to the pharmacy to the dispensing of drugs at the bedside.

For Opelousas General Health System (OGHS) in Opelousas, La., the solution came from Mountain View, Calif-based Omnicell Inc. “We were looking for a product to improve patient safety and reduce medication errors in our facility,” says Jared Lormand, OGHS’s chief information officer. “We needed a product that would simplify the process and automate our medication administration by using bar codes.”

Interestingly, poor communication problems between nurses and the pharmacy were one of the issues contributing to the organization’s medication error rates, Lormand says, and, the situation wasn’t helped by evenings and night shifts, when typically no on-site pharmacist is available. But Donna Copper, R.N., OGHS’s chief nursing officer, says even when a pharmacist was available, there were “multiple phone calls and multiple questions.” In many cases, the questions pertained to the appropriateness of specific drugs or a request to clarify an individual order. And on occasion, there was also finger pointing, according to Lormand.

By installing a system that uses an automated MAR (Medication Administration Record) and provides nurses with alerts as to possible drug/drug, drug/food or drug/allergy interactions, the human factor and, therefore, the possibility of human error, was taken out of the equation, Copper says.

OGHS began rolling out the bulk of Omnicell’s MedGuard system between 2003 and 2005, according to Lormand. The hospital first invested in the vendor’s medication dispensing cabinets, then purchased SafetyMed RN, a nursing workflow automation solution for the bedside that uses bar coding, and then SafetyPak, a barcode medication packaging system. In addition, OGHS installed OmniLinkRx, which currently allows physician orders to be electronically faxed into the pharmacy’s system. “We’re considering buying a CPOE (computerized physician order entry) system, but for our size organization, price is a consideration. At 193 beds, we can’t afford to buy the latest and greatest software each year. We have to alternate our capital purchases with building buildings and installing the latest diagnostic equipment.” Plus, he notes, “With the best-of-breed technology we have here, finding a CPOE that plays well with other systems is hard to do.”

Process Improvements
Yet, the decision to purchase the Omnicell solution and to automate the process was driven solely by concerns over patient safety issues, which seems to remain the number one provider concern in the healthcare arena, ever since the well known Institute of Medicine study turned all eyes onto patient safety several years ago.

Not only does the system eliminate those parts of the process where human error can cause problems, but it greatly simplifies the entire process. Prior to rolling out this automated system, physicians would write their orders and nurses would fax the orders to the pharmacist, who would then enter each order into the McKesson pharmacy information system, and then file away the paper fax, Lormand says. After medication labels were printed and the medication cart filled, the nurses would use a paper MAR to verify which drugs were to be given to which patient.

Now, after the physician signs an order, it’s electronically faxed directly into the pharmacy’s dual monitor workstation, Lormand explains. Then, while viewing the electronic physician order on one monitor, the pharmacist enters the order into the pharmacy system on the other. A message is automatically sent to the SafetyPak system, which prints out and affixes bar-code labels onto each patient’s individually wrapped medication.

When it’s time to dispense these medications, the nurse logs into the system and scans her badge, which brings up her list of patients. Then, she scans the bar code on the patient’s wrist band, which brings up a list of all meds to be administered to that patient. Once the nurse scans the bar code on the medication package, the system automatically checks the “five rights” (right patient, right medication, right dose, right time and right route). “If there’s an error or an alert, she calls the pharmacy immediately,” Lormand says.

Overcoming Hesitancy
Not unlike other hospitals that have installed similar bar code-based medication systems, OGHS did experience some early resistance from the nursing staff. “Most nurses had not had to use computers before,” Lormand says, “so we had to teach them how to use Windows and how to use a mouse, then train them on the software.”

Switching from a paper MAR to an electronic one also presented a challenge. “That was traumatic for a lot of nurses,” he admits. “Some of them held on to the paper MAR for three weeks to make sure the computer was right.” The additional time it takes to bar code at the bedside became another challenge. “The process is slightly longer, but they’ve begun to trust the system,” says Lormand. “And if there’s any issue about patient care or safety, they can use the system to prove their actions. Now, they’re dependent on the system.”

Taking extra time at the bedside and automating the entire medication-use process by using an end-to-end system with built-in alerts has definitely paid off for OGHS. Because most common errors involved drugs that look alike or sound alike, Lormand says, “We have seen a 66 percent reduction in medication errors housewide.” In addition, the Omnicell solution has reduced by one-half the amount of time required for a pharmacist to fill orders, which now allows the pharmacist to spend more time on the floor as an integral part of the healthcare delivery team.

Analyzing Data
The ability to perform data mining tasks has been a key factor in the patient safety efforts at Kapiolani Medical Center for Women and Children in Honolulu. Melinda Ashton, M.D., medical director for patient safety and quality services at Hawaii Pacific Health, the health system that owns and operates the 200-bed Kapiolani Medical Center, says being able to tap into clinical databases associated with the hospital’s EMR has allowed physicians to monitor specific symptoms that often show up in newborns and their mothers.

Relying on an early X-Windows (UNIX) based EMR from San Diego, Calif-based CliniComp International, Kapiolani Medical Center, which delivers about 5,000 babies per year, initiated a program called the Center for Health Outcomes, designed to promote and support physician-directed quality improvement. “It’s to answer questions about the care being provided,” says Ashton, “and it’s the physicians who are asking the questions.” Between 30 and 40 physicians have been involved in this project since it was launched in early 2004.

By combining CliniComp’s clinical documentation and EMR solutions with ICD-9 codes, financials, and infection control data, the hospital has been able to track key disease factors in order to deliver better long-term outcomes. Ashton says the program consists of four major projects.

Data as a Foundation for Improvement
The first is screening for severe jaundice in normal newborns, implemented in March 2005. This project was set up to determine the risks for severe jaundice and to provide physicians with the results prior to discharge. The goal was to eliminate severe jaundice, an entirely preventable problem, which can cause brain damage in babies. “The American Academy of Pediatrics, in 2004, came up with new guidelines for managing jaundice in newborns,” Ashton says. “The CliniComp system allowed nurses to document the results of screening tests on newborns and to look up what those results meant based on the Academy standards.”

But as a result of this screening program, the highest levels of jaundice were eliminated. There are no babies with a bilirubin count over 24, which characterizes severe jaundice, and fewer babies with a bilirubin count over 20 compared to babies who were not part of the screening program. The results of the study even had an effect on Ashton herself. “I used to be less concerned about jaundice,” she says. “But now, I find myself paying closer attention to those babies at higher risk.”

The Newborn Special Care Nutrition Management Program was designed to reduce the risk of complications in babies fed intravenously for more than 14 days; the goal was to accelerate the conversion to oral feeding. Evaluation of three years worth of data pertaining to the care of premature babies began in 2001, but the project was actually launched in 2004. Several definite patterns emerged from this study, leading to the creation of standards for the way babies are fed in the newborn special care unit (NSCU). As a result, IV feedings were reduced from 20 days to 11 days, and the infection rate dropped dramatically. Ashton says that the CliniComp system allowed for “the standardization of the approach, and also allowed us to look at the results of these standards.”

A project to reduce nosocomial infections in the NSCU was actually part of the hospital’s contribution to the Institute for Healthcare Improvement’s “100,000 Lives Campaign,” this project was begun in the fall of 2005. The EMR can be mined for data to indicate when improvements in care have been successful. Better central line management and an emphasis on hand washing resulted in a significant reduction in hospital-acquired infections, Ashton notes.

Finally, a project to reduce infection rates in laboring patients began in early 2004 and continues today. This program’s goal is to reduce infection rates among women in labor. “We tried to understand the factors involved in women developing fevers during labor,” Ashton explains. “Fever likely represents an infection that needs to be treated.” Infection rates during labor are about 6 percent nationwide and are usually caused by bacteria, she says. But while the mother may have the infection, her child also is at greater risk for the same infection.

As a result of this study thus far, Kapiolani Medical Center has improved the way it induces labor and the way it administers epidurals, Ashton says. Tracking both mothers and babies required tapping into huge amounts of data, but as Ashton notes, “We used the CliniComp system to gather the data and mine the data. We wanted to make sure we were not missing any infected babies.”

The emphasis of each of the projects was to improve patient safety, so collectively, the four projects showed physicians where improvements were needed. There was little resistance on the parts of these physicians to make the necessary changes to improve healthcare outcomes. “Once they understand the data, they can change their practices,” says Ashton. “Having data on our own patients changes their minds.”

Drug Databases, an Integral Clinical Management Component

The drug database that is the keystone of the automated medication system at Willis-Knighton Medical Center in Shreveport, La., has been in place so long that few employees can remember a time when it wasn’t.

“We have had it at least 15 years,” says Alicia McPherson, R.Ph., a staff pharmacist and the pharmacy’s project manager. Serving this hospital admirably through all those years has been a series of databases from Medi-Span, now part of the Clinical Tools division of Indianapolis-based Wolters Kluwer Health.

According to McPherson, all 35 pharmacists in the four hospitals that make up the Willis-Knighton Health System rely on six major Medi-Span databases: the Master Drug Database which includes national drug codes, drug names, ingredients and pricing information; the Drug Therapy Monitoring System; IV Incompatibility Database; Allergy Database; Drug Disease Database; and Patient Education Database. All of these databases are fully integrated with MEDITECH’s pharmacy information system, she adds.

McPherson says one of the greatest values in being able to access these databases is in reducing drug/drug interactions. “With all the new drugs on the market, physicians may not know all the possible interactions. Medi-Span works with Willis-Knighton to augment patient safety by educating the medical staff about new drug interactions.” To avoid such errors, the clinical staff can pull up drug/drug interactions and see Medi-Span’s recommendations as to how to handle those interactions, she says. At that point the pharmacist can print out the interactions for the nurses and physicians. This enables the medical staff to evaluate the interactions and clinically monitor the patients, she adds.

In further explaining how these drug databases can reduce errors, McPherson Notes, “Say the pharmacy receives an order from a physician for a Cordarone IV drip along with a Zithromax IV. The two together could cause life-threatening cardiac arrhythmias. But Medi-Span would flag that order as a problem. The pharmacist could then review the interaction information, share it with the physician and prevent any potential harm to the patient.”

Willis-Knighton Health System has yet to decide on a CPOE system. However, Johnathan Lee, network administrator, information technology, says, “All medication orders are scanned to the pharmacy using Galactica RX. Both routine and stat orders are scanned into the system at the nurses station and are electronically transmitted over an Ethernet network.” Once the pharmacist receives an order, he or she enters that order into the MEDITECH system “which automatically goes over to the Medi-Span page,” says Pleschette Roberson, supervisor of operations, Financial Systems.

McPherson adds, “If the pharmacist notes any interaction that is considered to be significant, the physician is notified immediately.”

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For more information about MedGuard, SafetyMed RN and other patient safety solutions from Omnicell,
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Richard R. Rogoski is a free-lance writer and contributing editor to HMT. Contact him at rogoski@aol.com.