Leapfrog Group outlines what is acceptable

The Leapfrog Group’s research suggests that its health care initiatives could radically reduce medical errors in the United States if only health care providers would implement them expeditiously. And to encourage their implementation, the group has outlined exactly what it would consider acceptable action by providers.

To compile statistical measures on how effective the changes might be, the group used the same basic analysis strategy for each of the three safety standards. Researchers first estimated the population at risk — the number of patients who are currently receiving care in suboptimal conditions and thus stand to benefit from changes imposed by Leapfrog. To avoid access issues and other unintended consequences, The Leapfrog Group exempted hospitals in rural areas. Thus, the population at risk is restricted to patients in metropolitan areas.

Then the group estimated baseline risks (of medication errors or mortality) in hospitalized patients, and the potential risk reductions associated with each of the safety standards. This is a summary of the potential benefit from full implementation of the three initiatives and how The Leapfrog Group expects providers to comply:

Computer-based physician order entry (CPOE).

The group estimates that implementation of CPOE in every nonrural hospital in the United States would avert approximately 522,000 serious medication errors each year. Because of the relatively few studies in this area, the analysis relied on two well-recognized trials from a single teaching hospital. The Leapfrog Group acknowledges that some may question the validity of generalizing these data to other hospitals nationwide.

"However, we chose the most conservative estimate of CPOE effectiveness [55% medication error reduction rate] for our baseline analysis," the group reports. "Although a large proportion of serious medical errors is life-threatening, the number that result in fatalities cannot be determined precisely from the medical literature. Accordingly, we did not calculate the number of deaths potentially avoided by CPOE. However, if only 0.1% of such errors were fatal, over 500 deaths would be avoided every year. If the fatality rate were 1%, over 5,000 deaths would be avoided."

CPOE systems are electronic prescribing systems that intercept errors when they most commonly occur — at the time medications are ordered. With CPOE, physicians enter orders into a computer, rather than on paper. Orders are integrated with patient information, including laboratory and prescription data. The order is then automatically checked for potential errors or problems. The Leapfrog Group says the specific benefits of CPOE include prompts that warn against the possibility of drug interaction, allergy, or overdose; accurate, up-to-date information that helps physicians keep up with new drugs as they are introduced into the market; drug-specific information that eliminates confusion from drug names that sound alike; improved communication between physicians and pharmacies; reduced health care costs from improved efficiency.

In order to meet Leapfrog’s CPOE standard, hospitals:

1. Require physicians to enter medication orders via computer linked to prescribing
error-prevention software.

2. Demonstrate that their CPOE system intercepted at least 50% of common serious prescribing errors, using a testing protocol specified by First Consulting Group and the Institute for Safe Medication Practices.

3. Require documented acknowledgment that the physician read the directives to any override.

Despite the considerable benefits, The Leapfrog Group says fewer than 2% of U.S. hospitals have CPOE completely or partially available and require its use by physicians. The upfront cost of implementing CPOE is one major obstacle for hospitals. At Brigham and Women’s Hospital in Boston, the cost of developing and implementing CPOE was approximately $1.9 million, with $500,000 maintenance costs per year since. Installation of even off-the-shelf CPOE packages requires a significant amount of customization for each hospital and can be very expensive. Finally, there may be cultural obstacles to CPOE implementation. For example, many physicians resist the idea of ordering prescriptions via computer instead of by hand.

Evidence-based hospital referral (EHR) — 2,581 lives saved in five high-risk procedures; 1,863 lives saved in high-risk deliveries.

The Leapfrog Group says the greatest number of deaths would be prevented by evidence-based hospital referrals for coronary artery bypass graft surgery (1,486 deaths), followed by elective abdominal aortic aneurysm repair (464 deaths), and coronary angioplasty (345 deaths). Potential lives saved with esophagectomy and carotid endarterectomy were 168 and 118, respectively. The analysis estimates the benefits that could be achieved with full adherence to Leapfrog volume standards in all U.S. metropolitan hospitals. The other two Leapfrog safety initiatives — CPOE and IPS — involve all-or-none hospital interventions. Making these changes for Leapfrog employees implies their availability to all other patients at the same hospitals. In contrast, even if EHR could be increased for Leapfrog employees, there would be no mechanism for assuring the same change in referral pattern for other patients.

"For this reason, a very important contribution of the Leapfrog safety initiative may occur by simply increasing public awareness of the importance of volume for selected high-risk procedures," the group says.

For high risk neonatal intensive care, full implementation of EHR for high-risk deliveries would save 1,863 babies’ lives each year in the United States, 1,369 lives for deliveries involving very low birth weight babies and 494 lives for deliveries involving babies with major congenital anomalies.

ICU physician staffing (IPS) — 53,850 lives saved.

The Leapfrog Group maintains that IPS is so effective because such a large number of people die in ICUs each year (approximately one-half million). Thus, even small improvements in ICU mortality rates save many lives.

The group acknowledges that although work force issues have not been studied carefully, it is unlikely that there are currently enough board-certified intensivists to fully staff ICUs at all hospitals. And the group says that in hospitals with small units, meeting the Leapfrog daytime intensivist staffing standard may increase net cost per stay. "For these reasons, broad implementation of intensivist model ICU staffing may require a mixture of increased fellowship training slots in critical care, consolidation of small ICUs, and advances in ICU telemedicine."