Technology reduces hospital medication errors
Technology reduces hospital medication errors
System caught 17 near misses in February
Jim Douglas, RN, clearly remembers the medication error he made. "It was Lidocaine," he says. "Thank goodness my patient lived." Since that time, Douglas decided to become active in the effort to reduce medication errors. Now he is the site coordinator at Northern Michigan Hospital in Petoskey for the installation of technology that acts as a double-check for caregivers administering medication to patients.
Rather than expecting perfect performance from caregivers in today’s complex health care environment, facilities need to use technology as a backup check for people, who can make mistakes, Douglas says. "We have 65 steps in the [medication dispensing and delivery] process, from the tip of the physician’s pen to the tip of the patient’s tongue. That’s 65 steps with the potential for error. The nurses at the end of this pipeline never have had any technology to help protect them from these system errors.
"When the errors do happen and cause harm, sometimes [administrators] look for someone to blame, and they ask the nurse, Why didn’t you catch that?’" he continues. "[The nurses] are trying their best to take good care of their patients, but they are only human."
Douglas says that 85% of the time, medication errors are a result of an error in the system. "That is what we are trying to improve."
Caregivers who are trying to dispense and deliver medications correctly have several factors working against them, says Donna DuLong, vice president of marketing for Bridge Medical in Solana Beach, CA:
- Caregivers need to know a vast amount of information about the drugs they handle. "Because of the tremendous advances in drug manufacturing over the last several years, new drugs are coming on the market at a pace that no human can keep track of all the knowledge needed to skillfully prescribe and administer those medications. It’s an enormous amount of information for everyone to process," DuLong says.
- Drug manufacturers craft clever names for their drugs, but the names often sound like other drugs on the market. These drugs that have similar names may have totally different purposes, DuLong explains. One drug could help with seizures, one with arthritis. "Having a system intervene and ensure that there is no confusion is a safety net for the consumers as well as the clinicians giving the medications."
- Caregivers work in disruptive environments. "Patients are increasingly ill, and nurses get interrupted many times in the course of their workloads. It makes sense to have a system that makes sure that they are following the task that they began before they were interrupted," she says.
Northern Michigan Hospital implemented the Bridge Medication Management System, which uses bedside computers with color-touch screens that interact with a radio-wave-controlled communication system wired into the ceilings of hospital hallways. Changes in medications, dosage levels, and other patient information can be instantly communicated from the hospital information systems to the bedside unit.
The nurses barcode the drug to be administered, the patient ID bracelet, and their own ID badge. The system then verifies these five rights:
1. the right patient;
2. the right drug;
3. the right dose;
4. the right time;
5. the right route of administration, such as intravenous or injection.
The system already knows what medications and dosage have been ordered for the patient. If the system detects any problems with the medications as they are being administered to the patient, it alerts the nurse with a message and provides another course of action for the nurse to follow. Possible problems include:
- The nurse scans a dose that exceeds what was ordered for the patient.
- The nurse gives the medication on the wrong day.
The new system automatically records when a medication dose is given, which staff member gave the medication, and other information. It produces reports allowing managers to monitor the medications given to patients and helps hospitals identify opportunities for improvements in their medication administration procedures.
"Management realizes that once you make [the administration of medication] electronic, you have data that you can analyze and look for trends for performance improvement," Douglas says. "We have been providing that to the managers on the [medical and surgical] floor."
Phase 1 of the system installation took place last December on the hospital’s medical and surgical floor. The floor has about 60 beds but has an average census of about 40 to 45, Douglas says. In Phase 2, in the spring, the system was upgraded with a different architecture.
Since the installation, Douglas says the system gives a nurse an error message almost every day. "The nurse cancels the delivery, steps away from the patient, and puts the drug back or gets the right drug. That’s what it’s all about."
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