Ideas that work for error reduction
July 1, 2000 2 minutes read
Ideas that work for error reduction
Simple solutions can reap big rewards
With medical errors having such a high profile in the news, many hospitals are grabbing headlines with their efforts to make a positive impact on patient safety. But it isn’t always a splashy and expensive idea that has the biggest impact. Sometimes a small, simple idea can make a difference.
At Luther Midelfort Hospital in Eau Claire, WI, a thorough chart review showed that most medical errors happened due to a "faulty handoff," says Roger Resar, MD, the "change agent" at the 300-bed facility.
"When you come into the hospital, the medications you take at home aren’t always continued. When you go from one unit to another, the same problem might occur. When you are discharged from the hospital, we forget you might have other drugs you will add in at home. We were seeing 200 plus errors per 100 admissions. And in 56% of the cases, there was not adequate communication about drug regimens."
The answer was simple: reconciling medications. The nurse or pharmacist looks at admitting orders and all the medications the patients are taking on the outside. That information might come from the patient or a family member, but barring that, a call to the patient’s primary care physician or area pharmacies can help fill in the blanks.
At the other end of hospitalization, all the medications the patient is taking as an outpatient and those that are the result of the patient’s hospitalization are printed on a report. The nurse, physician, and pharmacist all look over that list. "If there is something we didn’t want you taking in the hospital but want you to continue at home, we add that in," says Resar.
The pharmacist, the physician, and the hospital each get copies of the report. The pharmacist then makes up a spreadsheet calendar for the patient that includes information on when the patient should take each medication.
Just by making sure all the medications a patient is taking are known, one busy medical unit reduced its error rate by 82%, Resar says.
Steve Meisel, PharmD, assistant pharmacy director at Fairview Southfield Hospital in Edina, MN, saw another simple solution reap big rewards. "A few years ago, we changed our policy so that if elderly patients are taking sleeping pills and the dose hasn’t been appropriately adjusted for their age, we automatically convert it."
In 1995, five patients fell out of bed due to over-sedation. After the change in procedure in 1996, that number fell to zero and has stayed there since.
[For more information, contact:
• Steve Meisel, PharmD, Assistant Pharmacy Director, Fairview Southfield Hospital, Edina, MN. Telephone: (952) 924-5894.
• Roger Resar, MD, Change Agent, Luther Midelfort Hospital, Eau Claire, WI. Telephone: (715) 838-3566.
• Sharon Lau, Consultant, Los Angeles. Telephone: (323) 644-0056.
• Trudy Day, RN, Clinical Nurse Manager, Northern Michigan Hospital, Petoskey, MI. Telephone: (231) 348-4000.]
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