Report from IHI's 19th Annual National Forum on Quality Improvement in Health Care, December 9-12, 2007, Orlando, Florida

In this National Forum Workshop presentation, two medication safety experts report on efforts at their hospitals to prevent medication errors.

Presenters

• Kerry L. Butler, PharmD, MBA, Medication Safety Officer, Saint Thomas Hospital
• Lynn E. Eschenbacher, PharmD, Medication Safety Officer, Duke University Hospital

Presenter: Kerry L. Butler, PharmD, MBA, Medication Safety Officer, Saint Thomas Hospital

The Setting

• Saint Thomas Hospital, a member of Ascension Health
• 541-bed hospital located in Nashville, Tennessee

The Situation

The hospital desired to continue and expand its high-alert medication harm prevention package, which was developed as part of IHI’s 5 Million Lives Campaign.

The Solution

• Gap analysis, an assessment tool used in industry to compare actual and potential performance, can reduce the number of adverse drug events (ADEs) by identifying risks before ADEs occur, encouraging deliberate application of recommended practices, and reducing the time required for process change.

• The hospital used both “vertical” and “horizontal” analysis to identify possible gaps between actual and potential performance in preventing ADEs.
  • The group used vertical analysis — comparing each recommendation in the 5 Million Lives Campaign How-to Guide: Prevent Harm from High-Alert Medications with current practice — to clearly identify gaps in performance. 
  • Using this step-by-step assessment, the team identified the areas of greatest risk and opportunity for improvement.
  • The group used horizontal analysis — assessing potential technology solutions by drug class rather than by individual medications — to reduce the cycle time for implementing changes.
  • Instead of planning and implementing changes for each high-risk drug class sequentially, the group used a general framework that would apply to any of these drug classes. For example, rather than collecting information on blood glucose level to assess risks associated with insulin usage, the technology is designed to collect and display information on “dose-response effects,” which applies equally to insulin, narcotics, sedatives, and anticoagulants. Horizontal analysis allows the hospital to review performance gaps relating to all high-risk drug classes in one pass.

• Based on the results of the vertical and horizontal analysis, Saint Thomas Hospital designed a reminder system with a generic foundation that can be used for all high-risk drugs. For example, instead of creating a flagging system with reminders of the most recent blood coagulation studies when Coumadin is ordered, then creating another system with reminders of the most recent blood glucose level when insulin is ordered, the hospital created a flagging system that displays an electronic pop-up screen with lab results relevant to any of a number of high-risk medications when these drugs are ordered.

• The hospital also implemented an electronic medication administration record (eMAR) throughout all units, with roll-out in less than one year. The system allows for deployment of several changes that support the quality initiatives, including medication reconciliation and use of administration guidelines.

• In an effort to fully engage staff in ADE prevention, the hospital now requires all staff to take a class on ADE prevention taught by physicians, hospital executives, and safety officers. In addition, the hospital created and distributed a list of safety-related expectations.

The Future

The hospital plans to continue efforts to increase “behavioral accountability,” seeing this as a critical link in achieving high reliability in ADE prevention.

Presenter: Lynn E. Eschenbacher, PharmD, Medication Safety Officer, Duke University Hospital

The Setting

• Duke University Hospital, part of the Duke University Health System
• 924-bed hospital located in Durham, North Carolina

The Situation

• Recognition of the role that human factors play in errors
• Desire on the part of the hospital to achieve as close to zero medication errors as possible

The Solution

• Application of Six Sigma methodology to reduce variations in practice and errors

• Six Sigma involves five basic steps:
  • Defining the problem
  • Measuring defects
  • Analyzing sources of variation and identifying potential causes
  • Improving the system
  • Controlling and maintaining improvements

• The hospital has used the Six Sigma approach to better understand the human factors that account for errors and to create systems that prevent and mitigate such errors. For example, the hospital now has standardized concentrations throughout all units to avoid dosing errors and has switched to tubing that cannot be connected unless the connection is indicated (e.g., epidural and intravenous tubing are no longer compatible and thus cannot be mistakenly interchanged).

• The hospital also implemented a computer physician order entry (CPOE) system that includes standardized order sets and decision support. The CPOE system warns providers who order opiates, for example, to consider the multiple risk factors for respiratory depression and to base dose on lean body weight, avoiding overdosing in obese patients.

• The hospital uses an electronic ADE surveillance system to identify potential drug errors. Each day the pharmacy is alerted to these events, providing pharmacists with an opportunity to intervene and potentially prevent ADEs.

Measuring Results

The hospital currently uses a voluntary reporting system and expects data on ADE rates to be available in the near future.

For More Information

View the PowerPoint presentation for this Forum Workshop session:  

Proactive Approaches to Reduce Harm from High-Alert Medications Presentation

01/31/2008