Transcript Graham Billingham - The Eighth Mediterranean Emergency

Medical Error Prevention in the
Emergency Department
Solutions for the Future
Graham Billingham, MD
The Second
Mediterranean Emergency Medicine
Congress
Sitges/Barcelona, Spain
September 15, 2003
“I will do no harm”
Hippocratic Oath

Medical error is the fifth leading cause of death in
the United States. More people die from medical
errors than from car accidents, breast cancer or
AIDS.
The Institute of Medicine 1999

“Medication errors are one of the most common
causes of avoidable harm to patients”
Joint Commission Report 1995
“To Err is Human”

We have met the enemy and it is us
 Institute of Medicine Report 1999
 The Public will not tolerate medical error
 Leapfrog Group – payers will not tolerate
 Joint Commission – governmental mandate
 Institute for Safe Medication Practices
 Other industries have embraced information
technology, why haven’t we?
The Truth
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180,000 unnecessary US deaths per year
1.3 million injuries per year
$ 8 billion increase in national health costs
Cost- adds $4700 per hospital admission
1.4 medication errors for every hospital admission
The largest cause of adverse events in hospitals is
Adverse Drug Events (ADEs) which occur at the
alarming rate of 65 per 1000 hospital admissions
 60% may be preventable
Source: NCVHS Data
Adverse Drug Events
Who’s at fault?
Physician responsible – 56%
 Nurse responsible – 34%
 Secretary – 6%
 Pharmacy – 4%

Source: The Advisory Board
Common Physician Issues
Illegible signature – 78%
 Orders not timed – 58%
 Incomplete orders – 24%
 Illegible orders – 20%
 Other: too busy, distracted, verbal orders,
no checks and balances, rely on memory,
not aware of drug allergy or interaction

Common Nurse Issues

Calculating dose
– 80% incorrectly calculate 10% of the time
– 40% make mistakes > 30% of the time

Administering the wrong medicine
 Giving medicine to the wrong patient
 Frequency errors
 Missing doses
Medication Errors
Effect on US Malpractice

3% of total malpractice claims
 Average malpractice award = $636,000
Cost of Claims

Short term morbidity anaphylaxis, respiratory
failure, GI bleed
 Long term morbidity renal failure, anoxia,
death
 Difficult to defend
because of “expert
witness” (PDR/FDA
indications)
Medical Errors- Root Causes
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Allergic reactions
Excessive dose
Incorrect drug given
Error in writing or reading Rx
Drug interaction
Failure to monitor drug levels or toxic
effects
Medical Errors –
Where do they occur?

28% in ordering
 11% in transcribing
 10% in preparing
 51% in administering
JAMA 1996; 274-35-43
Why Do Errors Occur?
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Time pressure/high patient volume
Failure to recognize high risk areas
Medication delivery system is complex
Multiple caregivers involved
Extensive medication knowledge base
Poor communication (verbal/written)
Lack of checks and balances system
Pitfalls In Medication Delivery Systems:
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Request for
medication
administration
Nurse identifies
correct medication &
dosage
Patient identified
Allergy ruled out
Medication
administered correctly
•
Legible correct
prescription
• Pre-printed
instructions
• Pharmacist-patient
communication
• Compliance
High Risk Areas
Joint Commission (JCAHO)
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Began tracking 1995
Medical Error Prevention Issue 1-1998
High Alert Medications Issue 11-1999
Sound-alike Drug Names Issue 19 -2001
Dangerous Abbreviations Issue 23- 2001
Root Causes of Medication Errors
1995-2002
Sentinel Event Trends:
Medication Errors (% of total)
Medication Errors : High Risk Areas

High alert
medications
 High risk patients
 High risk diseases
 Infusion pumps

Verbal orders
 Abbreviations
 Look-alike drugs
 No standardization
 Lack of automation
Medication Errors : High Risk Areas
(JCAHO) High Alert Medications
Potassium Chloride
Opiates and narcotics
Insulin and oral hypoglycemic agents
Anticoagulants (Heparin)
Antihypertensive agents
Psychiatric medication
Anticonvulsants
Cardiac drugs
High Alert Medication
KCL Example
Potasium Chloride
• 10 incidents of death
– 8 from direct infusion
– 6 cases KCL mistaken for another drug
- Heparin
- Lasix
- Saline flush
•
Recommendation: must be stored and
prepared in the pharmacy
High Risk Patients and Diseases
Pregnant
Elderly
HIV
Transplant patients
Anticoagulants
Allergies
Pediatric patients
Psych Patients
Patients on 2 or
more drugs
CHF
HTN
Diabetes
Renal failure
Liver failure
Psych disorders
Medication Errors : High Risk Areas
High Risk Patients
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Pregnant
Elderly
HIV
Transplant Patients
Anticoagulants
Allergies
Psych Patients
Patients on 2 or more
drugs
Digoxin
Coumadin
Aspirin
Elavil
HCTZ
Enalapril
Zantac
Indocin
Xanax
Zithromax
Medication Errors : High Risk Areas
High Risk Patients
Multiple Medications

2 medications = 13% chance of
an ADI
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7 medications = 87% chance of
an ADI
47% of patients discharged from the ED have a
new medication added
Digoxin
Coumadin
Aspirin
Elavil
HCTZ
Enalapril
Zantac
Indocin
Xanax
Zithromax
Medication Errors : High Risk Areas
Pediatrics
Medication Errors in a Pediatric Emergency Department.
Selbst SM et al. Pediatr Emerg Care 1999.
 Incorrect
Dose = 35% of errors
 Incorrect Medication given = 30% of errors
 Incorrect recording of weight
 Failure to note drug allergy
High Risk Areas: Infusion Pumps
Major Source of Medication Errors
• High risk medications
• Inadvertent free-flow
• Incorrect pump programming
• Calculation / concentration errors
• Wrong medication
Case Study
30 y/o F history of post strep AGN s/p renal
transplant. Presents with URI symptoms.
Meds : cyclosporin, Prednisone
Dx : bronchitis
A. Cipro
B. Zithromax
C. Erythromycin
D. Biaxin
Medication Errors:
Solutions for the ED
Recommendations/Summary
Give medication only if
indicated – do no harm

Physician verifies PMHx, meds and
allergies
 Be aware of FDA/PDR recommendations
 Give least toxic drug
 “Low and slow” rule
 Be aware of high risk patients
 Be aware of high risk medications
Medication Rules
 Consider
contraindications
 Consider drug interactions
 Consider adverse drug event
 Use bolus rather than infusion when
available
 Monitor drug levels when appropriate
 Avoid prescribing medicine outside of the
scope of emergency medicine
Medication Errors: Prevention
Drug Administration
Infusion Pumps
• Pumps with free-flow
protection
• Standardize
– Medication use
– # Of critical care drugs
/ concentrations (
premix)
• Check system
• Document dose
calculation on chart
• Limit number of pump
types
“SMART” Infusion Pumps
• Drug infusion protocol
library
• Pre-defined dose limits
• Automatic shut-off
• Alarm system
• Integrated Patient
Monitoring
– Vital signs
– Allergies
– Age / Renal Function
The Future: Taking the Human
Out of the Err
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Reduce the reliance on memory
Pre-printed drug dosing protocols
PDA/bed side aides/wall charts
Automated drug dispensing
Standardize formulary
Automated drug calculator
Computerized Physician Order Entry
Clinical decision support
“Intelligent” EDIS
Medication Errors: Prevention
Drug Administration
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Use Pre- printed
Protocols
Medication Errors: Prevention
Drug Administration
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Use Wall Charts
Medication Errors: Prevention
Drug Administration
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Use Bedside aides
Medication Errors: Prevention
Drug Administration
Personal Digital Assistant
Medication Errors: Prevention
Drug Administration
Automated Drug dosing and Distribution
Medication Errors: Prevention
Improve Communication
•
Standardize Prescriptions
“unit” vs. “u” 20U NPH for 200 NPH
 “every” vs. “q”
 “use leading zero, not a trailing zero”
– 0.4 not .40
– 4 not 4.0
– 2 ½ not 2.5
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Medication Errors: Prevention
Improve Communication
Patient
– Dosage
– Simplify regimen
– 4 X day vs every 6 hours
– Indication, side effect, duration
– Pre-printed instructions
– Include family
Medication Errors: Prevention
Improve Communication
Medical staff
• ID bracelets
• Limit use of verbal orders
• Beware of look alike/
sound alike
• Call out system
• Check System
• Share plan with team
Medication Errors: Prevention
Improve Communication
Caution with sound a likes / look a likes
 MgSO4 vs. MSO4
 Diprivan vs. Ditropan
 Narcan vs. Norcuron
 Nifedipine vs. Nicardipine vs. Nimodipine
 Brevital vs. Brevibloc
Medication Errors: Prevention
Include Pharmacist
Pharmacy Responsibilities
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Legible prescriptions
•
Controls all patient’s
medication
Checks for drug
interactions
Special Packaging
Provide information
sheet/Patient education
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Medication Errors: Prevention
Computerized Physician Order Entry
(CPOE)
Benefits
• Legible
• Decreases number of hand-offs
• No verbal orders
• Guidelines displayed
• Alternatives offered
• Appropriate doses and frequencies
• Built in alerts, allergies and interactions
Medication Errors: Prevention
Computerized Physician Order Entry
(CPOE)
Challenges
• Changing behavior
• Equipment availability
• Equipment / software failure
• Requires training
• Orders entered on wrong patient
• Cost
Computerized Physician Order Entry (CPOE)
Effect of CPOE on Prevention of Serious Medication Errors.
Bates DW, JAMA 1998; 280: 1311-16
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Serious Medication Errors
55%
Decrease hospital LOS by one day
Decrease hospital charges by 13%
Adverse Drug Events
– Actual
– Potential
17%
84%
The Role of Emergency
Department Information Systems
(EDIS)

Passive tracking of patients
 Medical error prevention tools built in
 Improves documentation and legibility
 Automates workflow – reduces hand-offs
 CQI tools for outcomes research
 Provides clinical decision support
 Automates prescription writing
The Future
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Bar code/RFID tracking
 Design EDs around “Do no harm” principle
 Standardization of medications and processes
 Automation of workflow and systems
 CPOE becomes the new standard of care
 Intelligent EDIS with clinical decision support
 Pharmacy robotics and intelligent drugs
Final Thought

One thing is clear, our societies will not
tolerate this rate of medical error, and
neither should we. As it turns out,
embracing information technology will be
the easy part, changing human behavior will
be the challenge of the future.
Web Resources
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www.ismp.org
 www.nccmerp.org
 www.iom.edu
 www.jcaho.org
 www.mederrors.com
 www.advisoryboardcompany.com
Implementation of an EDIS
A Case Study
Clifton A Sheets, MD, FAAEM
Mary Washington Hospital
Fredericksburg, VA USA
Introduction
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Why an EDIS?
Search Process
Selection Process
Implementation
Impact
Considerations
Disclosure
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A consultant for Patient Care Technology Systems
 Amelior ED®
Why an EDIS?
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Process began in 1995
– 300 bed Community hospital
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Increasing ED patient volume
– 60,000 annual visits in 1995
– 87,000 annual visits (projected) in 2003
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Increasing ED length of stay
 Decreasing patient satisfaction with ED
process strongly tied to LOS
Why an EDIS?
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Paper/grease board/transcription
– manual system
– ineffective, and inefficient
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Need for patient tracking
 Need for automation of data collection and
processing
Driving forces
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Community pressure to reduce time in ED
 US Compliance Issues JCAHO, EMTALA,
HIPAA
 Fundamental belief that CQI should be more
proactive
 Patient Safety
– Handwriting issues
– IOM report 1999
– Medication errors
Handwriting..Isordil or Plendil?
Driving forces
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ED expansion planned
for 2002
– From 30 beds to 55
beds
– From 13,000 sq ft to
27,000 sq ft
Search Process
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Needs identified
– Streamlined patient
care
– Complete/compliant
documentation
– Reduced transcription
costs
– Enhanced patient
safety and error
reduction
– Optimized
reimbursement
Solutions identified
– Patient tracking
– CPOE
– Nurse and physician
charting
– Prescription writing
– Discharge instructions
Search Process
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Collaborative effort
– Physician champions identified (3)
– Nursing and hospital administration
– Administrative assistant
– Ancillary services
– Information Services
– Medical records
Search Process
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Sources of information
– EDIS trade shows and conferences
– Electronic bulletin boards
– Word of mouth
– ED Physician group prior exposure
Selection Process
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Vendor’s RFP
– Main players
– Beware of “vaporware”
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Best Few
– Complete systems
– Track record of success
– Desired features

Site visit to “kick the tires”
Selection Process
Selected “best 2” vendors with complete solutions
(late 2000)
 Site visits revealed problems such as incomplete
system feature implementation and stability issues
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Fear of failure
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Upfront cost
Physician use
Speed issues
Return on investment
Selection Process
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Amelior ED system identified as new
vendor
®
– Allergy and drug-drug interaction safety
–
–
–
–
features
Weight based dosing
Clinical decision support (protocols)
CPOE ease of use
Customization capability
Selection Process
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Amelior ED
®
– All-inclusive pricing based on patient volume
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Key challenges
– Beta site, no installations to visit
– Unknown company with unknown resources
– Hospital IS chief afraid of being stuck with a
legacy system, and no support
Amelior ED
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Clinical features
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®
Technology
– Patient tracking
– Microsoft®-centric
– Nurse charting
– Bedside workstations
– Physician charting
– Additional nursing and
– CPOE
– Prescription writing
–
– Discharge instructions
–
– Reports engine
– Forms engine
– Onsite user training
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–
physician workstations
ADT, Lab, X-ray interfaces
365 x 24 x 7 technical
support
Quarterly software upgrades
Hardware refreshes
Implementation
“big bang” vs phased approach
 Initial big bang in Nov 2001
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– Lack of complete lab and x-ray interface capability
– Speed and process issues resulted in a mutual
agreement to take the system down

Proof-of-concept in Fast track
– Completed interface work
– System turned on for rest of ED
Current Status
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Continuous operation since July 2001
 90,000+ visits
 100% use by physicians and nurses
 Bi-directional Interfaces:
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Lab orders and results
X-ray orders and interpretations
ADT information transfer
Lifetime clinical record
Impact
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Decreased LOS by almost 1 hr in 1st 6 months
– Volume has increased 14% this year
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Eliminated handwriting issues
– No more pharmacy call backs
– Reduction in medication errors
– Reduction in “missed” orders

Automated time stamp improved process analysis,
accountability, and order execution times
Impact

Greatly enhanced ability to determine prior
visit actions, results and treatments
 Reduced “door to decision” time
 Streamlined orders process
– Unit clerks eliminated from process
– Improved protocol compliance
Impact

Nearly paperless ED
– No “paper chase” for lab or X-ray results
– No fighting over who gets the chart
– No lost or misplaced charts

Improved transfer documentation
– Instant chart for the transfer now available
– Prompting for transfer (COBRA)
documentation
Impact
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Financial
– Reduced walk-outs by 57% (> $1 million annually)
– 90% reduction in lines of transcription ($300k annual
savings)
– Improved physician documentation

Increased RVUs
– Length of laceration
– Critical care time well documented
– Reduction in calls for medical records
– Automated ICD-9, CPT and APC codes
– Charge capture
Impact
Increased physician productivity = increased income
Average Physician RVU
2.25
2.2
2.2
2.15
2.15
2.1
2.05
2.05
2
1.95
2002
2003 YTD
Jun-03
Impact
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Concerns
– New technology introduces complexities
 New users
 Data entry
 Safety feature bypass
Impact
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Concerns
– Different looking chart
 Medical staff outcry over change
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Small but vocal minority
Education on benefits
Modifications in font size appeased most
Paper chart made available for consultants
– Additional layers of regulation
 Passwords
 HIPAA rules specific to EMRs
Summary

A full feature EDIS can
– Reduce errors and improve patient safety
– Eliminate handwriting issues
– Improve workflow by reducing turn around
times for lab, x-ray and nursing orders
– Improve data analysis and collection
– Enhance hospital and physician revenues
– Reduce length of stay
Summary
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Plan for an evolution and not a revolution
Needs assessment drives the process
Collaborative process
Physician champions key to success
Vendor environment is competitive and evolving
Biggest may not be the best solution for your ED
Future of EDIS

Bioterrorism monitoring and alerts
 Proactive CQI
 Enhanced automation
 Embedded digital imaging
 Artificial intelligence
 Mobile connectivity
“We have met future and
it is us”
Resources
Dr. Clifton Sheets
[email protected]
Mary Washington Hospital
www.medicorp.org
Patient Care Technology Systems www.pcts.com
EDIS Symposium www.paacep.org
AAEM www.aaem.org
ACEP Emergency Medical Informatics Subsection www.acep.org