A tool kit is offered for reducing medication errors

The California Healthcare Foundation is offering what it calls a practical tool kit for reducing medication errors in hospitals, one of the main problems cited in the recent controversy over medical errors.

Medical errors are the eighth leading cause of death in the United States, with the number of deaths exceeding those associated with motor vehicle accidents, breast cancer, or AIDS, the foundation notes. Medication errors represent the largest single cause of errors in the hospital setting, accounting for more than 7,000 deaths annually — more than the number of deaths resulting from workplace injuries.

The Institute of Medicine report that focused on medical errors made reference to information technologies that have been shown to be effective in reducing medical errors, particularly in hospital settings, and interest in this issue has grown among health care stakeholders. Prominent examples include initiatives by the Leapfrog Group, a consortium of large private and public companies that purchase health care benefits for more than 20 million Americans and, closer to home, the California State Legislature. Senate Bill No. 1875, which requires every general acute-care hospital, special hospital, and surgical clinic in California (with the exception of small and rural hospitals) to adopt a formal plan for minimizing medication-related errors as a condition of licensure. This plan, to be implemented on or before Jan. 1, 2005, must include "technology implementation, such as, but not limited to, computerized physician order entry or other technology" to eliminate or substantially reduce medication-related errors.

In order to assist health care providers with that initiative, the California HealthCare Foundation recently published A Primer on Physician Order Entry, which describes computerized physician order entry (CPOE) systems and provides case studies of hospitals that have implemented these systems.

As a follow-up to that piece, the Foundation commissioned Protocare Sciences to prepare a tool kit, which hospitals can use when considering how best to proceed in choosing and applying a variety of technological solutions, including CPOE, to prevent medication errors in the hospital setting.

The tool kit consists of two parts: "A Framework for Developing a Plan" and "Ten Tools." Both are available on the California Healthcare Foundation’s web site at http://quality.chcf.org/view.cfm?itemID=4194. A hard copy also may be ordered from the web site.