Patient Safety

1
Patient Safety

• Patient safety and reducing medical error has
  always been a top priority
• Institute of Medicine Report 1999
• More people die from medical errors each year
  than from suicides, highway accidents, breast
  cancer, or AIDS
• 44,000 - 98,000 deaths per year

2
Medical Error

• Causes Of Death In U.S. 1997
• Heart 726,974
• Cancer 539,577
• Stroke 159,791
• Lung 109,029
• Accidents 95,644
• Pneumonia 86,449
• Diabetes 62,636
• Medical Errors 44,000
• 
  CDC, IOM

3
Medical Error

• Medication Error
• A medical error that occurs during the medication
  use process
• 
  

4
Prevention of Medication Errors

• CPOE
• Computerized Physician Order Entry reduces errors
  in medication ordering
• 55 reduction in serious medication errors in a
  BWH study
• No impact on administration, dispensing, and
  transcription errors

5
Error Stage for Serious Medication Errors
eMAR
CPOE
6
Medical Error

• Medication Error
• A medical error that occurs during the medication
  use process
• 1.4 of BWH admissions using CPOE
• 92 minor
• 8 serious
• 7 potential (near miss)
• 1 preventable .001 or 1/1000 admissions
• 
  Bates, et al

7
Administration Errors at BWH

• Recent review of Jan-Mar BWH incident reports
• Electronic MAR with bar-coding would have
  prevented 66 of medication-related incident
  reports
• Incident reports are tip of the iceberg
• Approximately 5 of true event rate

8
Barcode Initiative

• Electronic Medication Administration Record
  (eMAR)
• Medications bar-coded in pharmacy
• Patients bar-coded with wrist bands
• Nurses IDs Bar-coded
• Nurses scan bar-codes to check and document
  medication administration

9
The Safe Environment

• Office for Patient Safety
• Centralized Provider Credentialing
• Options for Disruptive Physicians
• Enhanced Route Cause Analysis
• Standing Committees
• Specific Task Forces
• CCE

10
Office for Patient Safety

• Facilitate adoption of preventative initiatives
• CPOE
• Reduces serious medical errors due to ordering by
  55
• Medication reconciliation during handoffs
• Smart Pumps
• Reduces administration errors by ??
• Web-enabled Incident Reporting System
• Electronic Medication Administration Record
• Bar Code Technology reduces
• Transcription / dispensing errors by 80
• Administration errors by ??

11
Administration Errors at BWH

• eMAR
• Review of incident reports demonstrated
• eMAR with barcoding would have prevented
• 66 of medication-related incident reports
• Pharmacy study demonstrated eMAR with bar coding
  reduced dispensing errors by 80

12
BWH eMAR Timeline

• Proposed 1999
• Design / Development June 2001
• Drug repackaging facility 2003
• Initial eMAR Pilot CWN 2004
• Rollout 2005
• Estimated Cost 10 M
• BWH Staff 170

13
(No Transcript)
14
(No Transcript)
15
(No Transcript)
16
(No Transcript)
17
The BWH Drug Repackaging Center
18
(No Transcript)
19
(No Transcript)
20
(No Transcript)
21
(No Transcript)
22
(No Transcript)
23
Prevention of Medication Errors

• Impact of eMAR ?
• Too soon to determine
• But.

24
Effect of Barcode Technology on Different Types
of Dispensing Errors
56 reduction
71 reduction
90 reduction
p