Eliminating drug errors

A few years ago, a patient taking a long-lasting brand-name beta-blocker got switched to the generic short-acting medication when admitted to Geisinger Medical Center in Danville, Pa. At discharge, the medication instructions said, “Take all home meds.”.


A few years ago, a patient taking a long-lasting brand-name beta-blocker got switched to the generic short-acting medication when admitted to Geisinger Medical Center in Danville, Pa. At discharge, the medication instructions said, “Take all home meds.” The patient started taking both beta-blockers and ended up back in the hospital with a low heart rate.

It's a mistake that would never happen now that the hospital is nearly three years into its efforts to comply with Joint Commission regulations and the Institute for Healthcare Improvement's (IHI) adverse drug events (ADE) prevention initiative, which focuses on medication reconciliation. This plank was part of the IHI's 100,000 Lives Campaign, which ran from December 2004 to June 2006. The work on the intervention continues in IHI's 5 Million Lives Campaign, which was launched in December 2006.

“We had sloppy practices that happen much less to never now, like ‘Take everything like you used to,’ “ said John B. Bulger, FACP, director of inpatient services for general internal medicine at Geisinger.

The above story and other examples, he said, created a sense of urgency that helped Geisinger's staff acknowledge there were medication errors related to the reconciliation process and to overcome an initial concern that the fix was going to create more time-consuming paperwork. Now the 16 hospitalists at Geisinger Medical Center are doing more than working on the ADE committees. As elsewhere, they may provide the crucial continuity link that can drive ADE efforts.

“My goal is to have hospitalists involved in everything we can get them involved in,” Dr. Bulger said.

Geisinger's efforts—from having nurses get a patient medication list at admission to providing patient brochures at admission and discharge—are closing the loop on medication reconciliation. And while its clinics have been using a computerized prescriber order entry (CPOE) system for four years, the hospital is going live with its inpatient system this October.

The efforts are paying off. Medications that patients were taking before admission and those they receive in the hospital now match 80% of the time, up from 20% previously. And where once 30% of all discharge orders said “Do what you did before,” now each patient gets one list of medications to take and another of drugs that were stopped.

That's in step with IHI's goal of trying to reduce harm to patients—it's estimated that more than 770,000 people are injured or die each year in hospitals from ADEs—even if the patient ultimately recovers.

“Patients may do all right in the end, but we say we can do a lot better than this,” Dr. Bulger said.

Key to success

The IHI says one key to successful medication reconciliation is to have a multidisciplinary group—usually made up of a nurse, pharmacist and physician—evaluate the process and devise hospital-specific solutions to the usual problem spots: admission, in-hospital transfers and discharge.

“The medication problem is not a physician problem alone,” said James B. Battles, PhD, senior service fellow for patient safety in the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality (AHRQ). “It is shared by multiple players.” Dr. Battles stressed that pharmacy, nursing and IT all have to begin to work together to make an improvement.

Missouri Baptist Medical Center, a 489-bed hospital in St. Louis, Mo., has used a public educational program called “Mind Your Meds” to begin to address the problem of patients not knowing or being able to tell what drugs they're taking. The program, which has been presented to senior citizen groups, extended care facilities and even travel agents and rotary clubs, includes a credit card-sized reminder card.

Some hospitals use nurses and others use pharmacists to try to gather the information at admission and use a form to document which drugs should or shouldn't be continued, said Frank Federico, RPh, an IHI director who focuses on patient safety. That form is then referred to as new orders are written and medications change throughout the patient's stay so hospitalists don't have to dig through notes buried in the chart, he said.

Fairview Health Services, a system of seven hospitals in Minneapolis, felt the idea of reconciling two lists “was a waste of time,” said Steven Meisel, PharmD, director of medication safety. Instead, once the history is taken, that form becomes the template that follows the patient throughout his stay and discharge.

At that point, the physician only needs to check “yes” or “no” on a list of home medications and relevant inpatient medications. “It's pretty hard to miss something,” Mr. Meisel said. Plus, the list, when printed in patient-friendly language, becomes discharge instructions.

Missouri Baptist has addressed discharge reconciliation problems by uploading its completed discharge form to a secure clinical data repository on its intranet. There physicians find not only clinical documentation but also lab values and radiographic images. Plus, the computer system rids the hospital of a long-standing problem: illegible physician signatures, said John E. Krettek, MD, vice president and chief medical officer.

ADEs as eye-openers

Once a hospital starts looking at its reconciliation, it should be prepared to deal with problems it didn't know about: things that were missed, doses that were confused and omissions or other problems that occurred when patients moved from one level of care to another. Psychiatric, topical and aerosol drugs, for example, typically fall through the cracks, IHI's Mr. Federico said.

“But the sky is not falling,” said Dean T. Parry, RPh, Geisinger's director of clinical pharmacy programs. Instead, he said, uncovering the problems should be seen as an opportunity. “We found the holes in the system and now we can start to patch them or prevent them from happening at all,” he explained.

Finding out that more than 40% of patients coming to Missouri Baptist Medical Center in 2001 had some kind of ADE resulting in harm was a “huge eye-opener,” said Nancy Kimmel, RPh, patient safety officer. After implementing solutions, including providing a safety hotline for staff to leave anonymous reports, the hospital saw its average of 2.3 ADEs per 1,000 doses in 2001 drop to 0.14 ADE per 1,000 doses in 2004. The improvement has been sustained for over two years.

Geisinger uses a modified form of IHI's Global Trigger Tool to perform random chart reviews. The IHI recommends that two record reviewers (usually a nurse, pharmacist or respiratory therapist) sample 10 patient records every two weeks (spending up to 20 minutes per record) looking for any of 26 triggers, such as blood transfusion or use of blood products or oversedation/hypotension, and have a physician verify the results. The trigger tool can help hospitals focus their efforts on high-alert medications such as heparin, chemotherapy, anticoagulants, insulin and opiates/narcotics, which are a focus of the ADE initiative in the 5 Million Lives Campaign.

“The idea is not to beat up anybody who made a bad decision,” Mr. Parry emphasized.

Instead, the response is to make changes to address identified problems. For example, Hackensack University Medical Center in Hackensack, N.J., now provides pre-admission paperwork for scheduled patients on its Web site, said Bob Fakelmann, administrator of patient safety.

“In a perfect world we would have all the information up front, but we're still struggling with that ... until there's some way of providing medical information on a chip,” he said.

What's on the horizon

John B Bulger FACP reviews a medication reconciliation form at Geisinger Medical Center in Danville Pa
John B. Bulger, FACP, reviews a medication reconciliation form at Geisinger Medical Center in Danville, Pa.

The biggest change for most hospitals in the next five to 10 years is CPOE, according to Dr. Bulger, who noted that it's critical to make sure a good process is in place before CPOE is implemented. “The electronic system doesn't fix bad flows,” he explained. Plus, experts say it's critical that CPOE gets clinical decision support, or physicians will find the system frustrating.

And other challenges remain, such as how to handle hospital politics, how to find extra resources if needed or restructure existing staff and how to make sure the patient's primary care physician gets a copy of the discharge medication list.

Despite the hurdles, hospitals should feel optimistic about their efforts, according to Fairview's Mr. Meisel.

“This is hard work. It takes perseverance. But you can't allow yourself to get discouraged,” he said. “Improve what you can.”