Making the Leap to Avoid Medication Errors - Industry Trend or Event

Health Management Technology, Jan, 2001 by Leah Curtin, Roy L. Simpson

There's more than one way to improve patient safety.

First there was The Lancet Study (vol. 349, Feb. 1, 1997, pp 309-313) indicating that serious medical errors were up at least 500 percent since 1990--more likely 800 percent when the night shift is included. The Lancet Study results indicated a 17.7 percent serious error rate (not counting the night shift) as compared to The Harvard Medical Practice Study (1990) indicating a 3.7 percent serious error rate.

Then came the Institute of Medicine (IOM) Study, To Err Is Human, speculating that anywhere from 44,000 to 98,000 Americans die each year as a result of medical errors, then the Congressional hearings and the appointment of a Congressional Oversight Committee.

And now, 60 of the country's largest employers have come together in an organization known as the Leapfrog Group (www.leapfroggroup.org) to encourage hospitals to reduce medical errors. The companies in this group insure 20 million Americans; they and their employees account for more than $40 billion in annual healthcare expenditures, so you can be sure that their voices will be heard.

The Leapfrog Group, sponsored by The Business Roundtable, is a vehicle to mobilize corporate purchasing power to influence an increase in patient safety. Of course, employer purchasing coalitions are nothing new; for years, employer groups have influenced the products and prices of managed care companies and insurance carriers with their financial strength. What's new is the effort to effect improvement--leaps, in fact--in patient safety by rewarding higher standards and higher performance.

Successful Alternatives

But improvements in patient safety and reductions in medical errors need not harness the power of multinational corporation to be notable. The nation's huge VA system successfully launched a relatively inexpensive system that dramatically reduces medication errors.

For example, the Tucson VA reports an error rate of less than 1 percent and believes it can reduce it even more with this system. The system is called "Bar Code Medication Administration," and because taxpayer dollars were used to develop the software, it is available at cost (about $25). Related costs (for the Tucson VA) ran about $350,000 and included the costs of computers, cordless scanners and a server. It takes about one hour of training for staff to learn how to use it.

Here's how the system works: Patients wear a bar coded identification bracelet. The nurse waves a handheld, cordless scanner over the bar coded bracelet, which, in turn, brings up the patient's records on a laptop computer on the nurse's medication cart. The nurse then scans the bar code of the medication she is about to administer. The dosage is prepackaged in the pharmacy, using the same computer and bar coding system. Once a medication is given, the computer automatically records it. If the patient has already received the drug, the computer displays a red circle with a white X and tells the nurse that the medication already has been given.

As every nurse will tell you, the nurse is responsible for giving the right drug, in the right amount, by the right route at the right time to the right patient. This system pretty much assures that this will happen. While it lacks many of the features of other computerized systems, it goes a long way in reducing errors for a very reasonable price.

Leah Curtin, RN, ScD(h), FAAN, is editor-in-chief of CurtinCalls, an irreverent, fact-filled scan of nursing and healthcare, Cincinnati, OH. Roy L. Simpson, RN, FNAP, FAAN, is vice president of Cerner Corp., Kansas City, MO.

Editor's Note: Leah Curtin will moderate a roundtable discussion, "The Bermuda Triangle: RN Shortage, Patient Safety and Regulation," at at HIMSS 2001 in New Orleans. See program for details or visit www.himss.org.