Technology, quality focus can help cut medical errors

ICUs are particularly vulnerable to errors

Through a combination of technology, continuous quality improvement efforts and more effective collaboration, some hospitals across the country are finding ways to improve care, and in the process, reduce medical errors.

President Clinton announced in December a national drive to reduce medical errors, quoting studies that estimate up to 98,000 Americans die each year as a result of health care mistakes. (See related story, p. 18.)

ICUs are particularly vulnerable to errors, in part because their patients are particularly vulnerable to harm. They are sicker, with more complex problems, being treated with combinations of very potent drugs.

"It’s an area of high hazard for medications, an area of multiple drugs," says Hedy Cohen, RN, BSN, vice president for nursing for the Institute for Safe Medication Practices, a nonprofit organization that educates health care practitioners about adverse drug effects and their prevention. The institute reviews voluntary reports of medication errors submitted by hospitals and other practitioners.

Error prevention flows from QI errors

In the ICU, Cohen says, "We see a lot of pump errors, from multichannel pumps, where you have to label all lines going into patients."

And the squeeze to cut costs can put even more pressure on overworked units, leading to fewer of the backups that nurses once may have taken for granted.

At Henry Ford Hospital in Detroit, medical errors aren’t pursued in a vacuum, but as part of efforts to improve the entire process of care in the ICU, says ICU director Robert Hyzy, MD. As improvements are made that standardize procedures and address process-related problems, error prevention is the outcome.

To achieve that, the hospital focuses on three important aspects of care:

1. A closed ICU, in which critical care practitioners call the shots. While a specialist, such as a gastroenterologist, may consult on a patient, the final decisions about care are in the hands of critical care specialists.

2. Collaborative practice, or establishment of a close working relationship among physicians, nursing staff, and the critical care pharmacist. This collaboration takes many forms, including an enhanced rounding team that includes nursing and pharmacy and full participation by all parties in quality improvement efforts.

3. Protocolization of care, in which pathways are developed for all procedures. The goal of the pathways is to decrease practice variation, which in turn can lead to fewer errors.

"The biggest focus is towards standardization of things that can be standardized," says Kathleen Vollman, MSN, RN, CCNS, CCRN, clinical nurse specialist for medical critical care. "It’s clear in the literature that when you reduce process variation, you reduce the chance of missing things and of error."

Staff perform routine checks

In addition to following pathways, critical care staff perform a number of routine checks to backstop their work, say Vollman and Veronica Hall, RN, BSN, MSM, nursing administrative manager in the medical intensive care unit.

The computerized medication record for each patient is reconciled with physician orders every 24 hours. At the end of each shift, nurses do chart checks of all their patients to be sure all orders have been carried out.

"A lot of hospitals do 24-hour chart checks," Vollman explains. "We just moved it up so that each nurse is responsible at the end of their shift to re-review what’s been done during their shift, and make sure things haven’t fallen through the cracks."

Hall says that when the increased checks were instituted about three years ago, some nurses were skeptical. But when the system began to turn up errors, they realized its value.

"We immediately began catching errors," Hall says. "Most of it was little stuff, but we would show it to the person and say, Did you realize you did this?’"

Now, she says, when nurses find errors, they will write themselves up.

Creating an empowering environment’

It takes work to establish the type of empowering environment that encourages self-reporting — a major point in the Institute of Medicine’s report on medical errors.

"The first ICU I ever worked in, I wrote myself up — that was the culture," Vollman says. "It wasn’t punitive. The goal was to figure out how [the error happened]."

To achieve that sort of culture, consistency is important, as well as including nursing staff in the process of improving care.

At Henry Ford, a shared governance program provides the structure to include frontline personnel in decisions.

ICU nurses elect members to sit on hospitalwide practice and education committees. Those who participate are acknowledged through a career ladder and help improve care through their suggestions.

The result is quality improvement that percolates from the bottom up. When nurses called attention to a problem of ICU patients self-extubating, Vollman chaired a committee that looked into the reasons, a committee that included nursing, pharmacy, and a pulmonary fellow.

The result was a change in how patients were sedated to decrease agitation.

Nurses also suggested a two-party identification for matching blood products to patients. One nurse will read and spell the name of the patient, and read the medical record number to a second nurse, who will read it back to ensure accuracy.

Vollman says that the sense of empowerment didn’t just make nurses less fearful of self-reporting errors. It convinced them that there was value in collecting the data, if it could be used to improve overall care.

Hall says that value system is passed along to new employees by the seasoned nurses who precept them.

All this takes leadership from nursing administration. Although Hall has the advantage of working within a shared governance program, she says an institutionwide structure isn’t necessary to create an empowering environment.

"If I was a nurse manager who didn’t have a shared governance structure in place, I’d institute a unit committee to meet monthly on unit issues, practice issues," she says. "Let nurses make decisions on things they can reasonably have control over," such as scheduling policies or support programs for patients’ families.

Improved technology will help

Ultimately, with pressures mounting to keep staffing costs down, clinicians may need the benefits of improved technology to keep ahead of errors.

Some technology already is in place at Henry Ford. Hall describes a narcotics delivery system that requires a password and prompts nurses to count remaining drugs before and after removing a dose for a patient whose identification has been coded in.

Cohen says it’s becoming more common for drugs to be administered in standardized concentrations, rather than requiring nurses to mix up batches themselves and risk a calculation error.

Vollman would like to see the technology go even further, to perhaps have computers cueing nurses on all the steps required for a complex procedure, for example.

"The staff of today is so inundated with the amount of data and things they have to remember to provide good care," she says. "It’s not that they’re a good or bad nurse, it’s that they’re overwhelmed by all the pieces that they have to put together."