New Technology Could Reduce Hospital Drug Errors

  1. 0
    New Technology Could Reduce Hospital Drug Errors

    Issue Of Patient Privacy Still A Question

    POSTED: 9:02 pm EDT June 24, 2004
    UPDATED: 9:17 pm EDT June 24, 2004

    MADISON, Wis. -- The nonprofit Institute of Medicine said up to 100,000 people die each year from medical errors. But some claim that rate could be cut dramatically.

    Federal and local health officials at a University of Wisconsin health conference Wednesday said information technology holds the key to better health care.

    President George W. Bush and Secretary of Health and Human Services Tommy Thompson want a paperless health care system in 10 years or fewer.

    The issue will be coming up with an electronic medical records system that shares information with lots of doctors but still maintains patient privacy.

    "There are ways of making sure a patient's identity is protected, and that there would be releases from patients when their information would be shared to a different provider," said Kathy Heuer, assistant deputy secretary of health and human services.

    Federal officials said it's critical the government come up with a single computer language.

    In the meantime, technology that tackles medical errors is already in place at the UW Hospital in Madison.

    At the hospital, patients have to have a special wristband scanned before they get their drugs. The wristbands link the patients with software listing the proper drugs for them.

    "We obviously take care of whether we’re using paperwork to determine medication distribution or an automatic scanner, but mistakes can occur when people get busy," said UW Hospital oncology nurse Janice Parker. "It's a human-nature thing. This absolutely does protect us against that."

    In a pilot study in Parker's oncology unit, medication errors were cut by 87 percent since the wristbands have been in place.

    http://www.channel3000.com/news/3458427/detail.html
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  4. 0
    Quote from nursebedlam
    New Technology Could Reduce Hospital Drug Errors

    Issue Of Patient Privacy Still A Question

    POSTED: 9:02 pm EDT June 24, 2004
    UPDATED: 9:17 pm EDT June 24, 2004

    MADISON, Wis. -- The nonprofit Institute of Medicine said up to 100,000 people die each year from medical errors. But some claim that rate could be cut dramatically.

    Federal and local health officials at a University of Wisconsin health conference Wednesday said information technology holds the key to better health care.

    President George W. Bush and Secretary of Health and Human Services Tommy Thompson want a paperless health care system in 10 years or fewer.

    The issue will be coming up with an electronic medical records system that shares information with lots of doctors but still maintains patient privacy.

    "There are ways of making sure a patient's identity is protected, and that there would be releases from patients when their information would be shared to a different provider," said Kathy Heuer, assistant deputy secretary of health and human services.

    Federal officials said it's critical the government come up with a single computer language.

    In the meantime, technology that tackles medical errors is already in place at the UW Hospital in Madison.

    At the hospital, patients have to have a special wristband scanned before they get their drugs. The wristbands link the patients with software listing the proper drugs for them.

    "We obviously take care of whether we’re using paperwork to determine medication distribution or an automatic scanner, but mistakes can occur when people get busy," said UW Hospital oncology nurse Janice Parker. "It's a human-nature thing. This absolutely does protect us against that."

    In a pilot study in Parker's oncology unit, medication errors were cut by 87 percent since the wristbands have been in place.

    http://www.channel3000.com/news/3458427/detail.html
    At the Veterans Administration Hospitals we are using the above named computer program to administer medications. The bracelets with the bar code
    on them identifies the patient as the correct patient and shows the administrator what medications to give at that time. The nurse that is working anytime of day can look and see what medications need to be administered.
    explorer
  5. 0
    It only quadruples the time nurses spend keeping the system happy, IMO. Why is it all this hi tech stuff comes on board but the staffing never improves?? I feel like a nurse to machines and computer systems today vs a nurse for my very human patients.
  6. 0
    Quote from mattsmom81
    It only quadruples the time nurses spend keeping the system happy, IMO. Why is it all this hi tech stuff comes on board but the staffing never improves?? I feel like a nurse to machines and computer systems today vs a nurse for my very human patients.

    So true!!! The computer charting, the pyxis, none of it has made any difference to reducing time spent with paper and increasing time spent with patients.
  7. 0
    don't think the fact that the administration is attempting to squeeze nursing help to the last drop from nurses is the Medical Informatics Department fault.

    Medical orders that get into the computer are not medical orders that have legibility problems. As well once in the computer, analysis can be done.
  8. 0
    It is still possible for human error to cause the bracelet on the wrong patient (perhaps with the same name), the order to by typed into the wrong patients orders (anesthiologist visiting many pre op patients the same day), pharmacy could put the wrong sticker on the medication, and so on.


    Matts Mom is right. Without the nurse to assess the patient, give the medication correctly, and observe for efficacy or adverse effects all this money spent on high tech would be better spent on staff.
  9. 0
    The amount of time spent on development of the MIS system and the amount of time that the nurse needs to insert the data into the system should not distract from patient care.

    If the doc writes the order on the incorrect chart in the paper system the doctor still needs to correct the error.
  10. 0
    Quote from oneLoneNurse
    The amount of time spent on development of the MIS system and the amount of time that the nurse needs to insert the data into the system should not distract from patient care.

    If the doc writes the order on the incorrect chart in the paper system the doctor still needs to correct the error.
    You are probably right about the need for the doctor to correct the error.
    In my experience it is the nurse who points out to the physician that the error was made.

    The system could prevent the nurse from giving the medication to the wrong patient. I wouldn't mind having it. That would not prevent me from assuring that this medication is appropriate for this patient.

    Technology is no substitute for safe staffing.

    http://www.uchsc.edu/news/bridge/200.../lolafehr.html
    …” nurses intercept more than half of all medication errors that are detected before they reach the patient.”…


    Above is a short quote out of context in an article on preventing errors.
  11. 0
    I think we need to continue to pay attention ti the 'Five Rights'. With so many unit dose medications and the thousands of medications given the bar code could go on the wrong medication.

    Here is more on errors:

    http://www.hsph.harvard.edu/faculty/LucianLeape.html
    http://books.nap.edu/books/030906837...9.html#pagetop
    http://books.nap.edu/books/030906837...ml#page_bottom
    “Doctors accounted for 72% of the errors, nurses for 22%, pharmacy staff for 5%, and doctor/nurse combination for 1%”

    http://www.nursingworld.org/readroom/nti/9808nti.htm
    What kinds of factors are considered "systems failures" that lead to health care errors? The literature suggests that a broad range of factors needs to be considered. These factors include the following:
    • Interruptions in preparing medication (or preparing medication for administration);
    • Lack of education;
    • Illegible medical orders; faulty labeling (e.g., different medications bearing labels that appear similar, mislabeled medications);
    • Reliance on floor stock medication;
    • Overworked or overtired staff (unrealistically long resident hours, nurses working double shifts, insufficient rest periods between shifts);
    • Insufficient staffing; and
    • Faulty organization of patient care.
    One author describes human error in medicine as the mismanagement of medical care induced by such factors as the following (Bogner 1994a):

    • Inadequacy or ambiguity in the design of a medical device for the delivery of medical care.
    • Inappropriate responses to antagonistic environmental conditions, such as crowding and excessive clutter in institutional settings, and, in a home or field setting, extremes in weather and lack of power and water.
    • Cognitive errors of omission (and commission) precipitated by inadequate information, inappropriate mental processing of information, inappropriate actions stemming from adequate information, and situational factors, such as stress, fatigue, or excessive cognitive workload.
    • Compliance with unproductive and inappropriate policy.
  12. 0
    it will be a long, long time before barcode technology at the bedside is a reality in canada, i'm afraid. alberta is supposed to be on the cutting edge of innovation in health care in canada, and we're moving to an electronic patient record fairly soon in our health region. but, and it's a big but, in the quaternary care centre where i work we are still doing all our charting on paper, we are still charting far too much superfluous and duplicated information, our order sheets are a jumbled up mess with no particular format used and more than half of our patients don't have an id band on their person. most often the armband is taped to the bed... if we weren't staffed 1:1, this would be a huge problem.

    there have been a number of very serious med errors in alberta in the last several months. two elderly dialysis patients died when a pharmacy tech mixed kcl into their dialysate instead of nacl; these bags were both checked by three other techs and a student but still got through. and a man injured in an mvc got a fatal overdose of hydromorph instead of morphine in an er. the mistake was picked up within 15 minutes of the med being given, but the patient had already left the er and the staff were unable to contact him in time for treatment. there have been all the usual knee-jerk reactions and they've affected the entire province. in our unit (where we use a bucket of it every day) the kcl is now dispensed in 4 mmol doses that are kept under lock and key (through the dastardly pyxis) and there are also ten ml syringes containing 1 mmol/ml for our cv patients who persist in running serum k's of 2.2-2.6 post-op. we haven't had any fall-out from the hydromorph incident because ours is in the pyxis and the error is much harder to make. we are policy-bound to have all our meds double-checked and double-signed on the mar, so our drug error stats aren't too bad.

    and then too, the move to barcode technology would result in the need for unit-dosed meds, and we don't even have a pharmacist in the building (our quaternary care centre!!!) between 23 and 07. that could be a problem.


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