All Entries Tagged With: "Medication safety"
Patient safety in 140 characters
In honor of patient safety week, the National Patient Safety Foundation hosted a tweet chat, in which participants all follow the same hashtag (#keyword) to have a large conversation. If you missed it, you can read the conversation by searching twitter for “#PSAW2012.” I suggest checking it out (you don’t even have to have Twitter to conduct a search) for the resourceful links alone. Comment below or tweet @PSeditor if you joined and what you liked about it.
Here are some of the topics and facts brought up in conversation:
- Health literacy:
Twelve percent of adults have good health literacy
E-literature might help follow up with patients post-visit
MDs tend to interrupt patients after 18 seconds of speaking
- PSAW:
Getting PSAW recognized by more of the general public to spread awareness beyond the healthcare setting
Why PSAW is observed, recognized, but not celebrated
Next PSAW is March 3 –9, 2013!
Here are some resources brought up in conversation:
NSPF’s new “Ask Me” video
AHRQ’s “Questions are the Answer” video
IMSP has new tools and resources
Health Literacy: Reducing the Burden of a Complex Healthcare System
Patient Safety Week 2012: Informing the Journey, Not Changing the Destination
Checklists that patients and doctors follow can improve hospital care
Dreaming the dream (by Peter Provonost)
Navigating the Health Care System: Advice Columns from Dr. Carolyn Clancy
Do Electronic Medical Records Save Money?
What’s in a Name? Safer care, for one.
20 Tips to Help Prevent Medical Errors: Patient Fact Sheet
Texting while rounding :(
Everyone knows that texting while driving is dangerous—and illegal in many states. It’s obvious why: The driver gets distracted and takes his or her eyes–and mind–off the road.
But what about frontline care staff? Can they text on the floor? If so, when? Does your hospital have guidelines about this? Many hospitals are worried about the content of texts and other uses of social media, such as Facebook. They worry HIPAA will be violated. But a recent incident exposed on the AHRQ’s “morbidity and mortality rounds on the web” proves that texting while rounding, no matter what the content, can prove distracting and near disastrous, especially when smartphones serve as both a hospital tool for ordering medication and the portal to a resident’s social life.
The case involves a resident and intern who discussed the plan of care for a patient while rounding. An attending told the resident to stop warfarin until an echocardiogram of the heart could be taken.
Here’s a key part to this case: The hospital’s CPOE system allows providers to enter orders in the system through smartphones, a convenient option that allows real-time ordering. The resident began submitting the orders on her smartphone. Then she got a text about an upcoming party. The resident chose to respond to the text. The order for the patient was never completed, and the patient continued to receive warfarin for three days. Because of the CPOE system, no one reviewed the medication list, and everyone thought the order for warfarin was stopped. Though not stated in the case, I’m sure at least some of them thought they actually saw the resident put through the order on her phone.
The problem was realized when the patient developed shortness of breath, tachycardia, and hypotension from blood thinning. He needed emergency open heart surgery, and was in the hospital for three weeks before being discharged.
For those who use smartphones, it’s incredibly easy to understand how this happened. Once the decision is made to view a text (or if it pops up automatically), you are interrupted. Your screen is filled with only this text. You reply. Thoughts are now with that conversation, and there is nothing to remind you that another application is open, that you never finished the task.
Mobile devices and social media have brought personal lives into the workplace. However, when the finished product is a healthy patient, we need stringent rules for such devices. A personal phone call regarding a party would never be allowed on rounds. Nor would her friends, decked in party hats, be allowed to show up in person to disrupt her to find out whether she’s coming. But these scenarios are very similar to texting; you are communicating with others outside of your work, which brings thoughts elsewhere. Forget call lights and pages, this is the ultimate distraction because it’s intimate, private, easily hidden, and has absolutely nothing to do with work. Despite what we want to believe, no one can do two things at once, no matter how many apps you have.
It may be time to consider whether it makes sense to allow work and play to be conducted on the same device in healthcare. Mobile technology has many benefits, but perhaps the mobile devices staff use in the hospital to submit orders should be different than the devices they use to manage their social life. Many workplaces see this as a matter of etiquette. They trust employees to limit personal use of mobile devices during work hours. However, when you’re talking about the difference between sending a smiley face to confirm you’re attending tomorrow night’s party and submitting orders to stop an anticoagulant for a patient in danger of excessive blood thinning, you’re talking about much more than etiquette.
What do you think? What are your hospital’s guidelines on this?
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.
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.
Check out Consumers Union Web site for great patient safety
To stay up on the latest patient safety news and trends, I often find myself perusing various websites. Some of them are helpful, some not so much, but I wanted to let the readers of this blog know about one great resource I’ve been using from the Consumer’s Union. The Web page is called the Safe Patient Project and it has a wealth of information, resources, and action points for those visitors who want to try to bring about real change.
The site’s tag line, “end secrecy, save lives” gets at the heart of the culture of safety issue that so often comes up on this blog. Without a culture of safety, it’s difficult to encourage reporting of near misses and adverse events. This site gives a great overview of the legislation that is out there to promote accountability among healthcare professionals, as well as legislation on other topic like the prevention of medication errors.
Right now the Safe Patient Project is giving a lot of attention to the now well-known central line-associated bloodstream infection prevention checklist, developed originally by the Keystone project. It’s now being used in hospitals across the country, but if yours isn’t using it yet, this Web site will provide you with lots of resources to start.
What are some of your favorite websites for patient safety information? I’d love to hear your thoughts.
ASHP to The Joint Commission: Good steps taken in proposed revision to med rec
The American Society of Health-System Pharmacists (ASHP) has posted on its website its feedback to The Joint Commission’s proposed revisions to the medication reconciliation National Patient Safety Goal. Overall ASHP’s comments are that the changes made are positive ones, and that it is happy the accreditor has given hospitals more flexibility in implementing their own processes to comply with the goal.
At this time, the goal has just finished a field review and The Joint Commission is presenting the proposed goal to its The Joint Commission’s Standards and Survey Procedures Committee. The proposed goal pares down four goals with 13 elements of performance (EP) to one goal with five EPs. Notably missing is the requirement to provide a patient’s medication information to the patient’s physician or next provider of care. You can find more about the proposed goal in this earlier Patient Safety Monitor Blog post.
The accreditor is expected to announce the final version sometime in the coming months, with possible inclusion in the 2011 standards. The Joint Commission said that it has moved the location of the goal from its original location at goal 8 to goal 3, with the rest of the medication safety language.
For the most part, ASHP’s statement says that the organization agrees with The Joint Commission’s goal as written. However, some of ASHP’s specific recommendations include:
- Changing “obtain information” from the patient regarding medications to “obtain a medication list” to make the requirement more specific and useful.
- Further clarifying the definition of medication.
- Ensuring that the hospital collects at a minimum the name, dose, route, and dosing frequency of each drug, at a minimum.
- Comparing the patient’s medication list with the list of medications ordered for the patient in the hospital, and resolving those differences.
- Not only giving the patient a written list of the medications he or she should be taking upon discharge, but counseling the patient on taking his or her medications, to allow for questions.
You can find ASHP’s full comments on the proposed goal here. Did you submit feedback to The Joint Commission regarding the proposed goals? Do you have any specific feedback you would like to share on the PSM Blog?
Joint Commission announces field review for med rec
The Joint Commission has announced the field review of its revised medication reconciliation requirement, which it has designated as National Patient Safety Goal (NPSG) 03.07.01.
The field review comes after The Joint Commission announced it would make the existing medication reconciliation goal (NPSG 
one with which hospitals had to comply, but about which they would not be surveyed. The 2010 NPSGs contain language about medication reconciliation, but the field has widely expected an announcement about what will become of the goal.
The accreditor had previously said it would update the goal because it had received feedback from the field indicating that hospitals felt the goal was too difficult to implement. Last February, The Joint Commission said it would “evaluate and refine the expectations for accredited organizations.” The field review is the result of this refinement.
The revised goal is designed to work in tandem with other medication management requirements. It requires providers to maintain and communicate accurate information regarding a patient’s medications. Specifically, the goal would require hospitals to:
- obtain medication information from patients at admission
- compare that information with the medications ordered for the patient and identify discrepancies
- communicate to the patient at discharge information about the medications he or she should be taking
- impress upon the patient the importance of managing his or her medications outside of the facility.
The Joint Commission is asking for feedback from the field through May 11, although it would prefer feedback by April 30. The standard will be tested in the field prior to implementation. If you’d like to offer your feedback, and to see the full text of the proposed goal, visit The Joint Commission’s page about the field review.
Do you have any initial reaction to this proposed med rec goal? My sense from the field that any change would be a good one, and this seems to really simplify the goal.
Joint Commission changes wording in two National Patient Safety Goals
This week’s Joint Commission Online called attention to two changes made to the 2010 National patient Safety Goals. The following changes are effective immediately:
NPSG.03.04.01, Element of Performance 3: the date of preparation no longer needs to be indicated on medication or solution labels. The full list of what should be included is the medication name, strength, quantity, diluents and volume (if not apparent from the container), expiration date when not used within 24 hours, and expiration time when expiration occurs in less than 24 hours.
NPSG.07.03.01, Element of Performance 3, the word prevention was added to, which requires the hospital to educate patients (and families ) who are infected by MDROs about infection prevention strategies.
The second of these two changes really seems like a miswording issue, and doesn’t require anything different than originally intended. The first change is also not too significant, just reduces the burden on the person preparing the medication.
Any other thoughts?
Fat COWs ‘grazing’ in hall lead to BCMA workarounds
I had an interview with Ross Koppel, PhD, professor of sociology at the University of Pennsylvania last week about human factors engineering and its relation to patient safety. Koppel is also the principal investigator on the study of the hospital as a workplace and medication errors at the Center for Clinical Epidemiology and Biostatistics, School of Medicine at UPenn. We specifically talked about a study he was involved in that was published in the Journal of the American Medical Informatics Association in 2008 about workarounds used in conjunction with barcoded mediation administration systems (BCMA) and how they may affect patient safety.
He was a pleasure to talk to and explained the results of the study very clearly. He and his team found that clinicians used workarounds with BCMAs for 4.2% of patients, accounting for 10.3 % of medications administered. The reasons are numerous and all legitimate. But there is one reason that stuck out in my mind, simply because of the picture it left in my mind:
Fat COWs grazing in the hallway.
Of course COWs are not the kind that go ‘moo’ but are Computers on Wheels, COWs for short. One of the problems that Koppel and his team found was that some medication errors occurred because the COWs were too large to enter the patient’s room or is “tethered” to an electrical outlet, and therefore the nurse responsible for scanning the medication to administer to the right patient did so outside of the patient’s room. When the alarm went off notifying the nurse that the scanned patient ID was incorrect, he or she was already in the room administering the medications to the patient.
“That’s the reality and solving that problem is probably a $12 fix of getting a thinner COW, but only if you do the kind of observational work that I and my colleagues did are you going to figure that out,” said Koppel.
This was just one of the many examples of workarounds that Koppel and his team found, but it illustrates the need to apply human factors engineering to new patient safety projects, especially those that have to do with HIT. In the coming years this will be of the utmost importance. EMR implementation has the potential to really help hospitals unravel many communication issues. It also has the potential to make those issues even more complicated. By taking human factors engineering into account, vendors and clinicians can hopefully accomplish the former.
The economy may be weakening medication safety, patient safety
A survey undertaken by the Institute for Safe Medication Practices last fall has shown that the economic downturn has forced staff cuts, reduced the amount of technology and equipment that hospitals can purchase, and negatively affected the culture of safety by reducing the amount of time staff members have to report errors. Nearly 850 people took the survey and of those, 41% said the economy had a large to moderate negative impact on medication safety in particular.
Some specific findings concerning medication safety include:
- Forty-two percent of respondents said the staff person who dedicates time to medication safety (either a medication safety officer or quality improvement specialist) has had hours cut or his or her position completely eliminated.
- Less attention is being paid to the purchasing of safe medication equipment, such as using multi-use vials instead of single-use.
- Caregivers are more apt to rush drug administration practices as well as have less time to educate patients about their medications.
- Pharmacists are less likely to have a clinical presence on patients’ units.
To read more about the survey, click here.
Have you found that the economic downturn has negatively affected your patient safety practices?
