Preventing Medication Errors With New Technologies
St. Clair Hospital is a 331-bed acute care hospital in Pittsburgh. Each year management is required to report the number of medication error occurrences to the board of directors. Routinely, approximately 600 medication errors were reported. It was later learned that this number was underreported by a wide margin.
In March 2004, a “five rights” medication verification system was
implemented in the hospital. The system used bar codes on medications,
patient wristbands and on the nurses’ identification badges
(see Figure 1). The system,
called VeriScan by Sculptor
Technologies, enabled the
nurse to perform the five
rights of medication administration.
It was implemented
across all 16 of the hospital’s
nursing units over an eightmonth
period. Results were
then tabulated to examine
where errors were being prevented
and how the medication
delivery and administration
process could be
improved. Figure 2 presents
the results of three studies
that were performed and
identifies the frequency of errors that were caught and prevented.
Instead of the 600 medication errors reported per year, the hospital
was now preventing more than 5,000 medication errors per year.
After thorough analysis of the data, several conclusions were drawn. First, preventable errors occur at alarming rates. Second, the rate of wrong-med errors will decrease over time because the handheld system, through both positive and negative feedback, teaches the nurse to avoid the opportunity for error. Third, when hospital bed census and patient transfers increase, the number of wrong-patient errors increases and only a technological aid such as the handheld device can prevent the errors from occurring.
In 2005 the system evolved from using bar codes exclusively to a system that incorporates the use of RFID tags on the patient’s wristband and nurse’s badge. The goal was to speed the process of meds administration for the nurse. The cost to change to passive RFID tags was negligible because the medications remained bar-coded. The VeriScan system could now handle both bar code and RFID using a Socket dual-mode scanner. Voluntary nursing adoption of the system is a crucial success factor when implementing a five rights system. Although nurses readily adopt safe practices, there is still a reluctance to embrace a system that consumes more of their time. The addition of RFID tags made the meds verification process time neutral and improved nursing adoption to nearly 100 percent. Further driving successful nursing adoption is the automatic charting of the medication administration into the electronic medical record (EMR). Auto-charting removes that work from the nurse’s endof- shift responsibilities.
Another key to the process was utilizing pocket PCs with all the information at the nurse’s fingertips in the patient’s room, as opposed to leaving information on the mobile carts that are often left in the hallway. The pocket PCs operate on the hospital’s wireless network (802.11) and, with their bright, clear screen, the pocket PCs were readily accepted by the nurses. The pharmacist’s job – verifying the physician’s order and providing unit dose medications with bar codes on each package – was made easier through the use of an integrated pharmacy information system and robotic distribution.
Preventable adverse drug events (PADEs) have a cost to the
hospital in wasted medications, patient intervention and rescue,
increased length-of-stay costs, deaths and, of course, the anguish
the nurse experiences in making the mistake. St. Clair calculates
the system’s return on investment (ROI), as shown in Figure 3, and
found that the costs prevented covered the cost of implementation
in the first year.
Today St. Clair sees the nurse, using a pocket PC, as the center of all things related to patient safety at the bedside. The bedside safety system is being expanded to include verification to ensure lab specimens are labeled for the correct patient; programming “smart pumps” that administer IV solutions to the patient; checking dietary allergies with the meals provided; and making sure the right patient is receiving the right diagnostic test. These sound like simple things to verify, but in a busy hospital and busy departments, many unforeseen errors occur.
Unlike the traditional view that the meds administration process is an extension of the order entry system within an electronic medical record, St. Clair sees bedside prevention of medication errors as the first step in their enterprise RFID strategy. To deliver safe care, the nurse must be able to detach from the traditional EMR system that usually requires a full-size screen and a cart to mobilize it, and transition to a handheld device that easily travels with the nurse and is readily available at the bedside.When nurses are given a cart-based EMR and expected to bring it to the bedside for each encounter with the patient, the result is that nurses frequently leave the cart in the hallway and the associated patient safety stays in the hallway too.When nurses are given an RFID-enabled handheld device, they willingly bring it, and the associated safety mechanisms it offers, to the patient’s bedside.
Outside of the healthcare industry, manufacturers, distributors
and retailers have a thorough understanding of the utility
and efficiency that RFID technology delivers to their organizations.
RFID came into the public eye when, as a condition of
doing business, Wal-Mart and the Department of Defense
issued a mandate to suppliers to begin using RFID. Many suppliers
had a limited amount of time to come into compliance
with the requirement to apply RFID to all cases and pallets of
goods. Healthcare too is now learning how RFID can provide
value and solve problems within the hospital environment.
At St. Clair, a multidisciplinary team has constructed an enterprise
RFID strategy (see Figure 4) to encompass the future
RFID applications and provide a framework that allows compatibility
and coexistence for both passive tag applications and active tag applications. Regardless of the application or the
type of tag being used, the pocket PC represents a powerful tool
for the nurse to provide patient safety and save time on other
operational tasks.
For example, to alleviate the risk of dispensing the wrong IV mixture for the patient, the nurse can use the Socket dual-mode RFID scanner inserted in the handheld device to read the tag on the IV solution and perform the five rights of meds administration. If the patient then needs to be transported to the medical imaging department for a diagnostic test, the nurse can use the handheld device, access the asset tracking system and locate the nearest bariatric wheelchair. Once in the medical imaging department, the technologist can scan the patient’s RFID wristband to verify that it matches the order for a CT scan, and ensure that the patient doesn’t mistakenly receive an MRI instead. This type of capability represents healthcare IT automation that is just beginning to take hold and it goes well beyond the scope of the of traditional EMR systems. As healthcare organizations are challenged to deliver safer care and operate more efficiently, many must begin to look beyond the core functions that are integrated into EMR modules and consider the potential of extensible technologies, such as RFID, that offer a new suite of opportunities for automation. Being that the magnitude of the medication administration error rate is so large, it is logical to start with five rights medication verification capabilities as the organization’s first RFID application.
It is every hospital’s responsibility to provide a safe patient environment. This responsibility should take precedence over other aspects of conducting business at the hospital. In the delivery of care to the patient, there are a certain number of medication errors and other types of errors that will occur due to human error being involved in the process. Even in a patient care process that has been optimally engineered, errors cannot be completely eliminated without the introduction of a technological aid. RFID is an ideal technology to assist the caregiver at the bedside in eliminating the errors that threaten the patient’s safety. Systems, like VeriScan, are easily implemented, provide a proven and realistic ROI and should be part of everyone’s business.
