The Payoff: Preventing Errors Medication Management
Hospitals forge ahead with efforts to improve the way prescriptions get from clinician to pharmacy to patient
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Like many physicians, Angela Nichols, M.D., wears two hats: she’s the chief medical information officer at Susquehanna Health, a 282-bed health system in Williamsport, Pa., and is also a practicing physician. As such, she is well aware of the potential for medication errors. Still, she was shocked to learn that one of her patients, recently released from the hospital, was taking two cholesterol-lowering medications at the same time: Zocor, which Nichols prescribed, and Lipitor, which was prescribed while the patient was in the hospital.
While Nichols immediately instructed her patient to stop taking Lipitor, he did suffer some side effects, though none serious. The incident reinforced Nichols’ belief that it isn’t possible to do too much when it comes to eradicating medication errors.
Susquehanna Health is battling the problem on two fronts. The first involves implementing a medication management system that brings together everything from the physician’s initial order through the pharmacy, nurse and delivery to the patient. The second is a medication reconciliation initiative that will reduce the chance of conflicting prescriptions like the incident with Nichols’ patient.
“When a patient is transferred from one unit to another, or is discharged, is when there is a great chance of medication errors,” Nichols says. “We have to remind everyone that the medications that the patient is on in the hospital have nothing to do with the medications that the patient is on at home.”
Medication management isn’t a new problem for hospitals. But hospital executives are investing more resources to eliminate medication errors that endanger patients’ health. A commitment across a health system to not only upgrade systems but also to eliminate any remnants of a culture of blame can produce powerful results, even if it doesn’t benefit the bottom line in the short run.
“If we have saved one patient from a medication error, the investment has been worth it,” says Joe Butler, chief information officer at Hamot Medical Center in Erie, Pa.
An Overview
Because most hospitals already have pieces of medication management systems in place that they don’t want to replace, they are forced to develop work-arounds and meld software to the existing technology. This process is time-consuming and expensive, but reducing errors is such an imperative for hospitals that they are forging ahead, says Mitch Morris, M.D., principal, Life Sciences and Healthcare Practice, Deloitte Consulting LLP.
The effort is paying off. “It is difficult to quantify how much an electronic medication management system will save, but without a doubt there are significant savings in terms of cost avoidance from the medical errors that you otherwise would have made,” he says. “There are also some potential cost savings in terms of increased efficiencies gained by staffing more appropriately.”
Since Piedmont Health in Atlanta adopted its end-to-end medication management system in 2005, “we’ve demonstrated a 50 percent reduction in medical errors,” says John Hilliard, vice president and CIO of the two-hospital 600-bed health system. Still, the technical challenges, which Hilliard describes as a “hugely complex internal effort to develop interfaces that work safely,” paled in comparison with the cultural shift. “The system of managing medication by paper movement and duplication was so firmly entrenched that it was incredibly difficult to change,” he says. “So it wasn’t as much about fine-tuning the process we had; instead, we had to completely redo the process.”
To smooth the transition, Piedmont set up interdisciplinary teams to conduct training, as well as test units to work out the bugs before full deployment. “Errors spiked, but we were prepared for that and were candid with the staff that this would happen as errors that hadn’t previously been detected were caught,” Hilliard says.
The Beginning
Many health systems across the country have implemented electronic patient records as the first step in an electronic medication management system. “Once you have a patient’s medical record entered electronically, that information is available to the physician, pharmacist and nurses so that any potential drug interactions can be checked with what is being prescribed in the hospital,” says JoAnn Klinedinst, director of health care information systems for the Healthcare Information Management Systems Society.
That’s where Citizens Memorial Hospital, a 74-bed hospital in Bolivar, Mo., started in 2002. “We’re a little integrated health network with our hospital, five long-term care facilities, 16 physician offices and a home health care agency,” says CIO Denni McColm. “With all of our patient medical records on the network, doctors have access to that information in all of our 33 buildings.”
The Physician & the Pharmacy
If a systemwide electronic medical record is the first step, the next steps involve bedside verification and computerized provider order entry. While it may seem backwards, many systems implement bedside medication verification systems before CPOE. Under this scenario, physicians still prescribe manually; the order process becomes electronic in the pharmacy, where pharmacists enter the doctor’s order into the electronic medication management system.
To synchronize the pharmacy with bedside verification, most systems use bar coding, which generally starts in the pharmacy. Each dose of medication is bar coded and scanned into the system in a further effort to reduce errors. A study conducted by Beth Israel Hospital in Boston last year revealed that implementing a bar coding system in the pharmacy reduced medication dispensing errors by 85 percent, while the rate of potentially adverse drug events fell by 63 percent.
Even in the pharmacy, though, where most health systems have had automated systems for a number of years, adjustments and upgrades are frequently necessary. “We had to devise a pharmacy dictionary that contained all the information about the medications in our formulary and how those might interact with other medications,” says Joseph Raduazzo, M.D., chief medical officer at 113-bed Milton (Mass.) Hospital. In preparation for CPOE, Milton is also redesigning its medical records area so there are sufficient computer workstations for all physicians who want to input or change medication orders as well as sign off on electronic charts.
When CPOE is implemented, physicians, even those who are infrequent admitters, must master the new system because it will be the only way they can enter and change medication orders. Health system administrators and medical directors say the process goes more smoothly when physicians are brought into the decision-making process and kept fully informed as the build-up to the system going live progresses.
At the Bedside
When implementing bar coding technology at the bedside, health systems should do process mapping to figure out how the technology can be integrated and how workflow will change, says Valerie Fong, R.N., national patient care practice leader of Kaiser Permanente’s Health Connect electronic medical records system.
“Technology is the enabler of an elevated health practice system, not the end-all of the system,” Fong says. “If your processes are poor, the results will still be poor; technology enables better care, but it can’t do the thinking for you.”
Kaiser does process mapping on actual hospital patient floors and conducts simulation run-throughs at its Garfield Innovation Center, where there is a mock-up of a hospital floor.
Educating staff is another important piece of the puzzle. “That took significant time,” acknowledges Raduazzo of Milton Hospital. “We had to train every nurse on staff in the new system, which meant bringing them in here on their days off for training and paying them at the full rate. That’s a significant expense.”
Integrating the ED
Medication management in the ED presents unique challenges. “The difficulty is really related to the immediate nature of the decisions that are made in the ED in contrast to the workflow of the medical–surgical bedded areas of the hospital,” says Lisa D. McChesney, R.N., director of nursing and clinical systems at Hamot Medical Center. “ED physicians are present all the time to supervise the dispensing of medications. The stumbling block is getting the order into the system, and that’s the piece that we need to figure out before we can go there.”
At Piedmont Health, integrating the ED into its medication management system was incredibly challenging, but deemed necessary. “Having one part of the hospital doing things one way and another doing them another way was a problem,” Hilliard says. “We had to have everyone using these tools to drive quality.”
Susquehanna Health is incorporating its ED into the reconciliation process by reviewing prescriptions after the fact. “The concern among ED physicians is that a medication management system will prevent them from giving the meds that they need to give when they need to be given,” Nichols says. “We don’t want to interfere with patient care, but we need to know what is being given.”
Susquehanna Health administrators, physicians, pharmacists and nurses will review the ED prescription data to see what medications were prescribed for what conditions and review the appropriateness of the medication decision when it was made.—Amy Buttell Crane is a freelance writer in Erie, Pa.