CM can play critical role in reducing medical errors
NJ hospital takes process improvement approach
These days, virtually every hospital in the country is actively engaged in finding ways to reduce medical errors. Now, many are catching on to the fact that case management can play a pivotal role in this pursuit. The role of case managers in reducing medical errors is critical, says Michelle Gofney, director of case management at Deborah Heart and Lung Center, a 161-bed hospital with a full-service ambulatory care center in Mills, NJ. This year, Deborah Heart and Lung implemented an ambitious medical error reduction program.
"Case managers are the primary specialty voice to reduce medication errors," explains Gofney. Managers look at the patient’s medical care through the physician’s eyes and the nurse’s eyes as well as every ancillary department in the hospital, she adds. "They are the hub of the whole planning process."
Deborah was established in 1922 as a tuberculosis sanitarium and pulmonary center. After the development of antibiotic medications, the facility expanded its focus to other chest diseases. It added the specialty of cardiac diseases and evolved into the only cardiac and pulmonary specialty hospital in New Jersey. Today, Deborah offers surgical techniques and nonsurgical alternatives for diagnosing and treating all forms of cardiac, vascular, and pulmonary diseases in adults and congenital and acquired heart defects in neonates and children.
As a means of re-enforcing its ongoing effort to develop and maintain a "culture of safety" for both patients and staff, the Deborah Heart and Lung Center and the Deborah Hospital Foundation’s executive boards recently adopted a resolution that supports that commitment. The centerpiece of the resolution is a series of recommendations and directions of leadership, according to Carolyn Magnotta, RHIA, CPHQ, director of process improvement, who is responsible for managing the effort.
To more effectively coordinate and streamline medical error reporting, Deborah established six groups: Adverse Drug Event Steering Group; Incident Report Subcommittee; Peer Review Committee; Process Variance Team; Pharmacy & Therapeutics Committee; and the Ad Hoc Committee. The full scope of the organization’s medical error reporting efforts then was outlined in a medical error reporting grid. Each group was charged with achieving specific goals. For example, the Incident Report Subcommittee was tasked with developing an organizationwide incident reporting policy, which incorporates patient occurrences, employee occurrences, visitor occurrences, and security breaches as well as property loss or damage.
The Incident Report Subcommittee also was responsible for designing root-cause analysis for high-volume/high-risk occurrences to include musculoskeletal injury, patient falls, chemical or mechanical burns, infusion therapy injuries, medication administration, and monitoring errors, as well as skin breakdown injuries. The subcommittee also reviews and analyzes aggregate data for trends over time, supports education on reporting and investigating incidents, and recommends process improvement opportunities to the environment of care committee and QIC.
One major focus of many of the groups is medical error reporting, since a significant number of medical errors are attributed to this area. Multidisciplinary committees then are tasked with reviewing and analyzing all "unusual events" that either cause or have the potential to cause serious injury.
According to Magnotta, the Adverse Drug Event policy was revised to include definitions for medication error vs. adverse drug reaction. The policy also outlines reporting procedures, with all errors categorized to meaningful trending and analysis of reported events. In addition, a specific medication incident analysis report form was developed to assist in the reporting process, she adds.
In order to assess the current environment, the caregiver’s perception of the "culture of safety," and the ease in reporting, Deborah distributed a survey to all clinical staff and physicians in March. The set of 13 questions specifically addresses the perception these two groups have about the commitment of senior managers in the organization to communicate the importance of patient safety and facilitate adverse event reporting as well as the extent to which appropriate technology is employed to support that aim.
Magnotta reports that the response was fair. Results of the questionnaire were generally favorable, with the majority of respondents indicating that patient safety is a high priority. Respondents also reported that medical errors generally are reported and staff that do so receive support within the organization, she says.
The response that troubled the steering group the most was that a large number of respondents did not agree that a medical error is the result of a failure of a complex system when, in fact, data show that errors are most often precisely that. Deborah plans to address this problem through education at inservices, which will include all clinical staff.
According to Magnotta, the program outline includes an introduction from the executive director regarding the board resolution as well as administrative support for an environment of safety. The revised policy and tools for reporting will be reviewed and discussed, and survey results will be shared. Attendees then will be asked to participate in an activity demonstrating the impact of systems issues along with recommendations about how to evaluate systems and improve processes.
[For more information, contact: Carolyn Magnotta, RHIA, CPHQ, Director of Process Improvement, Deborah Heart and Lung Center, Mills, NJ. Telephone: (609) 893-1200.]
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