Sean M' Jeffery, PharmD, CGP, FASCP

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Connecticut Forum Quality Measures to Improve
Patient Safety

• Sean M. Jeffery, PharmD, CGP, FASCP
• Assistant Clinical Professor
• University of Connecticut School of Pharmacy
• Clinical Specialist Geriatrics
• West Haven VA Medical Center

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• What patient safety innovations and measures
  will help us reach better decisions about
  Connecticuts healthcare system and improve
  individual patient care?

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The IOM Report

• Report targets hospital errors
• Medical errors kill 44,000-98,000 people per year
• More people die from medical errors each year
  than from suicides, highway accidents, breast
  cancer, or AIDS
• These stunningly high rates of medical errors -
  resulting in deaths, permanent disability, and
  unnecessary suffering - are simply unacceptable
  in a system that promises to first do no harm.
  
  William Richardson

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Medication Use Improvement

• How many more people have to die before we
  accept that quality is everyones problem?

McGlynn EA, Brook RH. Keeping Quality on the
Policy Agenda. Health Affairs 2001 20(1)82.
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Serious and widespread quality problems exist
throughout American Medicine.These problems
occur in small and large communities alike, in
all parts of the country, and with approximately
equal frequency in managed care and
fee-for-service. . .Very large numbers of
Americans are harmed as a result.
Chassin MR, Galvin RW and the National Roundtable
on Healthcare Quality . JAMA 1998280(11) 1000-5
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What Does the Public Think?

• 42 of Americans report either experiencing or
  having a family member or friend experience a
  medical mistake within 5 years
• 100 million Americans
• Half those surveyed felt major problem was bad
  providers
• Three quarters feel getting rid of bad providers
  would be the most important change for improving
  the problem

Source Lou Harris, 1997
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Identify and Remove Bad Health Care Providers

• Advocated by some such as Sidney Wolfe
• Plays some role--there are a few bad apples
• Problem--will have little/no impact on system
  performance
• Almost all errors made by good people

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Root Cause Analysis Why Do Errors Occur?

• Errors are very common
• Complex cognitive mechanisms involved
• Slips--errors of implementation
• Low-level, semi-automatic behavior used for many
  routine daily activities
• Mistakes--errors of higher functioning
• Occur in new, or non-stereotypic situations
• Common causes include
• Distractions
• Overly high workload

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Faulty System Designin Hospitals

• Interruptions
• Look-alike packaging
• Sound-alike names
• Lamictal Lamisil
• Use of multiple infusion pumps
• Poor work schedules
• Work overload

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Medication Use Process
Adapted from JCAHO. Hospital Accreditation
Standards 2002. Oakbrook Terrace, IL Joint
Commission on Accreditation of Healthcare
Organizations2002111.
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Safety Models

• Aviation
• ASRS
• Immunity for reporting
• Supports policy improvement and planning
• Strengthens human factors research
• Anesthesia
• Team, workload analysis
• Standards
• Demonstrated mortality reduction

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Distribution Networks

• Partnering for safety
• Design for system error reduction
• Point of care interfaces
• Support technology for medication use

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Error in Medicine

• Most research from anesthesia
• Factors associated with errors (Gaba)
• Fatigue
• Boredom
• Excessive workload
• Communication failures
• Procedural changes have decreased injury rates
• O2 Monitoring and risk of ischemic brain injury
  during anesthesia
• Switch to unique oxygen yoke

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Systems Approach to Error

• Most important cause of error is faulty systems
  or design
• Assumes that individuals are doing their best
• Accidents result from defects in systems design
  that allow operator error to result in an adverse
  outcome

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Medication Use ProcessSystems Failures

• Errors,
• Drug knowledge dissemination 29
• Dose/identity checking 12
• Pt information availability 11
• Order transcription 9
• Allergy defense 7
• Medication order tracking 5
• Inter-service communication 4
• Other 14

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The biggest challenge is to get people in
hospitals- physicians, pharmacists, nurses and
administrators- to recognize that errors are
system problems not people problems.

• -Lucian Leape

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Bar Coding

• Technology edge for improving safety
• Most effective in linking dispensing and
  administration
• FDA consideration for mandates
• Consistency is needed

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Bar Coding

• Technology is inexpensive
• Would help in
• Matching medication orders and drug products
• Medications dispensed
• Medications administered
• Identifying correct patient
• Will know
• What/how much
• Who
• When
• Few data so far, but experience in other
  industries suggest important benefit

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Barriers to Automation of Dispensing

• Most products at unit-dose level not yet bar
  coded
• Hardware investment for hospitals
• Research hasnt yet documented benefits
• Links to hospital information systems needed

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Evolution of Prescribing

• Missing functionalities
• Timeliness
• Integrated communication and documentation
• Direct communication
• Beyond local healthcare system

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Electronic Prescribing

• Advantages
• Potential to function beyond local system
• Potential to enhance safety
• Data collection and reporting

• Missing functionality
• Continuum of care
• Removed flexibility of healthcare providers

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Robotics

• Mechanisms that integrate systems, software, and
  cognitive engineering
• Enhance the manageability of a complex system
• Dispensing
• Compounding
• Ensure presence of critical safety
  characteristics
• Barcoding
• Labeling
• Packaging

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Automated Dispensing Devices

• Advantages
• Control and security management
• Workflow standardization
• Drug information and alerts
• Formulary information and monitoring
• Improve first dose availability
• Consolidate / eliminate processes that do not add
  value
• Improve nursing satisfaction

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Have Pharmacists Workin Patient Care Areas

• Historically, pharmacists only involved post-hoc
• Closer collaboration makes intuitive sense
• Feedback is most effective when given at time of
  decision
• Studies suggest many errant orders can be
  intercepted
• See Brown, Am J Hosp Pharm 1991
• Most important in areas with high medication use
• ICUs, hematology-oncology units

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Reducing Error in Medicine

• I dont want to make the wrong mistake.
• Yogi Berra