All Entries Tagged With: "medication errors"
CoP revisions include patient administration of meds
The Centers for Medicare & Medicaid Services recently announced it would be revising some Conditions of Participation to ease documentation and administration headaches in hospitals.
However, as HealthLeaders Media quality columnist Cheryl Clark points out, such revisions include one that would allow, under certain circumstances, patients and/or their families to self-administer certain medications. The rationale is that some medications, such as eye drops, become a nuisance if a nurse must administer the medication when the patient is perfectly capable and was doing so before he or she was admitted to the hospital.
However, one of the problems is documentation. Can patients or family members be relied upon to document administration? What if the nurse administers the medication a half an hour after the visit of a sibling, who also administered the medication but got a phone call and failed to mention or document it?
More on this topic can be found at HealthLeaders Media, including the specific language of the change. What do you think of this provision? Is this a positive move toward patient-centered care, or a documentation—and potentially patient safety—nightmare waiting to happen? Share thoughts below.
Rewarding near-miss reporting
By now, most of us involved in patient safety understand the importance of reporting, collecting, and analyzing near misses. More and more, healthcare providers are beginning to understand that more often than not, a systematic problem—not an individual—is behind potentially dangerous errors.
But how do you get staff to report them? No really—actually report them? Including physicians? Many healthcare providers have been working in the field for decades, and for many of those decades, mistakes were swept under the rug—especially mistakes that luckily did not reach the patient. No harm, no foul, no reporting–this was a common way of thinking for many years. When providers have learned and worked in an environment where reporting errors often meant severe individual punishment, how do get them to trust you that reporting is okay?
It’s critical to show staff the positive effects of near miss reporting. It’s also a good idea to publicly and consistently reward those who “see/experience something and say something.” A good example is one surgical suite in Johns Hopkins Hospital in Baltimore that implemented its Good Catch Awards. After 24 months, the health center provided a table of 27 good catches that shows how systems were changed in response to the catch, including one that led to a national recall of an improperly labeled drug that lead to look-alike medication errors.
Clinicians honored with an award receive public recognition with wall boards on the surgical suite. The system is not yet implemented hospital-wide, but continues at the Weinberg OR Suite at Johns Hopkins Hospital.
Do you have a near-miss reporting system? Is it used? Do staff receive public recognition for their efforts? Have you had trouble getting staff to trust that reporting is benefits all? Post your comments below.
A dozen CA hospitals fined over patient safety issues
The California Department of Public Health (CDPH) has fined 12 hospitals for patient safety-related noncompliance, according to a CDPH release. The fines are for putting patients in “immediate jeopardy” of harm.
Out of 14 fines, eight were for failure to follow proper surgical safety protocol that resulted in objects left inside patients. A portion of the funds received from the fines will go toward improvement projects that focus on preventing this particular type of adverse event.
Hospitals that were cited in 2008 were fined $25,000, but a new law requires hospitals cited in 2009 and beyond to be fined $50,000 for the first citation, $75,000 for the second, and $100,000 for the third.
A detailed run down of each adverse event can be found at HealthLeaders Media. Other events include medication administration errors, medication storage errors, and failure to properly treat pressure ulcers. One patient fell out of bed, causing cardiac monitor to become disconnected. She later died.
New California law prompts healthcare facilities to report radiation overdoses
California hospitals have less than a year to adhere to a new law requiring the state Department of Public Health to be notified any time a patient is given a radiation dose in an imaging scan exceeding 20% of what was intended, reports HealthLeaders Media.
The new bill signed by Arnold Schwarzenegger won’t go into effect until July 1, 2012.
Recent overdoses of radiation in the state have prompted the new bill. Cedars-Sinai Medical Center in Los Angeles admitted to accidently giving 206 stroke victims eight times the dose of a normal radiation procedure, according to an article in The New York Times.
A two-year-old boy in a California hospital was administered an overdose of radiation which allegedly burned parts of his face, according to CW13.
The new law requires hospitals and clinics to record every radiation dose done on CT systems. The recorded doses then must be verified by a medical physicist. Healthcare facilities have five days to inform the Department of Health if anything goes wrong.
Read the rest of this article on California’s new law at HealthLeaders Media.
What do you think of the new law passed by California? Share your comments with us!
Physicians recall their shocking stories of what went wrong
The last thing a patient wants to hear is that their doctor made a mistake. An article published in Reader’s Digest gives doctors the spotlight in telling their horrific, sometimes fatal, mistakes made in the hospital.
I thought our readers would find this interesting. Read the stories of real life doctors whose career and lives were put on the line.
Well known patient safety advocates Peter Pronovost, MD, PhD and Robert M. Wachter, MD, among others, tell their stories of simple mistakes with dire consequences. Wachter recalls a mistake he made as a second-year medical student by simply failing to read a textbook chapter. The article is just another reminder that healthcare is slowly but surely becoming more transparent.
Have you ever made a mistake in a healthcare setting? Was it made transparent? Did you or the hospital learn from the mistake? We’d love for you to share below.
Joint Commission releases sentinel event stats, most challenging standards
The Joint Commission has released the 10 most frequently reported sentinel events. The Joint Commission gathers the information from its data base of voluntarily reported events since 1995, and cautions that the actual reported number of events “represent only a small proportion of actual events.” The top five are:
- Wrong-site surgery
- Suicide
- Operative/post-operative complication
- Delay in treatment
- Medication error
However, it’s worth noting that between March 31, 2010 and June 30, 2010 the most reported event was unintended retention of a foreign body (this even was not added to the list until 2005).
The Joint Commission also announced the top five requirements most frequently cited as non compliant for the first half of 2010. For hospitals, these included:
- RC.01.01.01, which requires complete medical records
- LS.02.01.20, which requires a means of egress
- LS.02.01.10, which requires proper fire protection features
- EC.02.03.05, which requires proper maintenance of fire equipment and features
- LS.02.01.30, which requires the building to have properly maintained building feature to protect individuals from fire dangers
It’s worth noting that no National Patient Safety Goals were included in the top five cited for hospitals
For more information, read The Joint Commission’s online publication, Joint Commission Online.
Leapfrog Group: CPOE systems should be monitored
I wrote up an article for HealthLeaders Media yesterday about a study released from The Leapfrog Group that shows that without thorough monitoring, computer physician order entry (CPOE) systems could potentially miss as many as one in three medication errors. The Leapfrog Group performed a simulation test using a web-based tool to test how often CPOE systems without modification could create potential adverse events.
You can read the full story by clicking here.
I’m curious about your hospital–CPOE is becoming pervasive and for good reason. CPOE can, when used correctly, prevent many medication errors from occurring. Has your hospital kept track of any potential problems or actual errors that have happened while using the system? Have you found that CPOE has made day-to-day responsibilities easier?
National Quality Forum endorses set of measure for managing medications
The National Quality Forum (NQF) has endorsed a set of 18 measures to better manage over-the-counter and prescription medications and improve the safety of using such medications. The standards focus on helping patients improve their adherence to prescription regimens. Specifically, patients with certain conditions, such as diabetes, asthma, coronary artery disease, kidney disease, chronic obstructive pulmonary disease, and schizophrenia, are more likely to be involved in a preventable adverse drug event due to incorrectly taking medication.
Up to 40 percent of patients do not take their medications as prescribed, and an estimated 1.5 million preventable adverse drug events occur each year. The National Quality Forum hopes these new standards will reduce these numbers by identifying gaps and areas to improve.
To read more from the NQF, click here.
Do you think the NQF’s latest set of measures will help those in the industry understand why certain patients are more at risk for an adverse event when taking over the counter prescriptions?
NEHI to launch medication initiative for patients with chronic illnesses
The New England Healthcare Institute is launching an initiative to investigate the reasons that some patients with chronic illnesses do not adhere to their medication regimens, and ways to improve adherence to taking prescribed medications. The initiative comes at a time when many patients with chronic care specifically are struggling to pay for the medications necessary for prevention. Patients with chronic conditions are more prone to healthcare complications if they do not adhere to their strict medication regimens. NEHI estimates that one third to one half of all patients with a chronic illness do not adhere to their prescribed medication regimens.
Other reasons that patients don’t stick to what their doctors advise for taking medications include forgetfulness, medication side effects, a break from illness symptoms, and low health literacy. Additionally, chronic patients who do not adhere to their medication regimens cost the health system $177 billion each year.
NEHI is hoping to identify strategies to boost patients’ compliance with prescribed medication regimens by creatively packaging medications, incorporating automated reminders into patient care, and using new patient education techniques, among other plans.
Study examines incidence of inconsistent communication present with CPOE
Computer Physician Order Entry (CPOE) has been thought to be one method to reduce the number of medication errors occurring at hospitals. Although there are many opportunities for a prescription error to take place when using a CPOE system, a new study attempted to examine the chance of an error occurring due to inconsistencies between the CPOE order and the notes field that allows for a physician to offer his or her own thoughts. The study, published in a recent issue of the Archives of Internal Medicine, found that while these types of errors are not common, they do occur and should be studied more.
The researchers studied CPOE records for four months at a tertiary care facility with the help of four pharmacists. The researchers compared any inconsistencies found between the prescription ordered an the notes in written in the free text field, and then determined that .095% contained inconsistent communication. Of those, 20% could have resulted in serious harm to the patient. The most frequent inconsistency found was dosage amounts.
Although this was a preliminary review, more research is necessary. The authors suggested a better interface for CPOE systems be incorporated as the technology improves.
Has your facility received feedback from those using a CPOE system about the “free text” field and whether it helps or hinders their use of the system?
