How To Stop Medication Errors

How to Design a Medication Safety Dashboard

Medication errors continue to be the most common errors in medicine. And this is after decades of work trying to fix this problem. We’ve used bar coding, double checks, triple checks, and no interruption zones, just to name a few. And they all help. But the problem of medical errors still continues.

I taught a one day workshop on Implementing Quality Programs for the Fall Institute of the American Association of Physician Leaders, formerly the American College of Physician Executives (ACPE) this past weekend.

We spent part of the day reviewing the major components in an Annual Quality & Safety Plan. We put the redesign of the medication administration process as a priority both within the Safety section and the Process Improvement section.

We did this because of the frequency of medication errors that persists in our hospitals – on average a hospitalized patient encounters one or more medication errors per day.

We also reviewed a template for a Medication Safety Dashboard. You know my favorite line by now: The only way to manage quality is to measure and report on quality. So here is a template for doing just that. It can be used throughout any organization, from the front line to the board room, to report and manage medication related errors. It’s also a great tool for physician engagement.

I’ve used some version of this Medication Safety Dashboard in many organizations. Click here to download an excel file and of course, feel free to customize as needed.

I would love to here from you. Do you have a medication safety dashboard you would like to share? If you do, just send me an email and I’ll set up a special page for sharing.

How a Medication Error Killed My Grandpa

Would "No Interruption Zones" Prevent Such a Tragic Outcome?

My Grandpa was one of my heroes. He had survived WWI, the Great Depression, and WWII, and yet, he still wore a smile on his face everyday. And he loved his grandkids, and his great grandkids.

I was taking the second part of the boards one day when the dean came into the auditorium and pulled me outside.

She said, “your grandpa has been in an accident. He’s over at St. Mary’s. Go to him and we’ll worry about this test later.”

I had just finished a cardiology rotation at this hospital and one of my professors was Grandpa’s cardiologist. This gave me a sense of hope that Grandpa would be OK.

My professor said, “your Grandpa has a pneumothorax (a collapsed lung); they put in a chest tube to reinflate it; his heart failure is stable; we fully expect that he will make a full recovery.”

I was so grateful my Grandpa had a good prognosis.

The next several days went off without a hitch, but then … three days later my professor called me aside, and he had a grave look on his face.

3 Reasons You Should Pay Attention to Leapfrog’s Hospital Safety Score

40% of Hospitals Receive a C, D, or F Rating According to Leapfrog

The controversy about healthcare’s rating agencies continues. Whether it’s that we don’t like their choice of measures, or how the data is risk adjusted, the most recent complaints are that there are too many of them and they all measure different things.

Regardless, rating agencies aren’t going away. Their measures and methods are becoming more sophisticated, and patient interest in hospital quality information continue to increase. And frankly, many quality leaders find their information useful and informative – some such as myself will use this information to help develop our quality and safety priorities for the near term. One such source is Leapfrog’s Hospital Safety Score.

Why You Should Follow Your Hospital Safety Score

First, Leapfrog’s Hospital Safety Score is targeted at consumers and is intended to help them “select a hospital that is prepared to protect them from harm and error.” This is reason enough to follow your score. It seems that anything less than an A, and possibly a B would be embarrassing. It’s also hard to explain when asked why your organization has a C, D, or F by the media, your board, your community leaders, your employers, and your health plan partners.

How to Solve Our Healthcare Patient Safety Crisis

And a New Resource That Can Help

We have a healthcare crisis of epic proportions – a patient safety crisis. It only came to light in the 1990’s, but its likely existed in all of our healthcare organizations for our entire careers. But so far, we have only made a dent in the problem. Our patients know this and they are afraid, their families are afraid, and when we’re honest with ourselves, many of us worry about being hospitalized in our own organizations.

Here are the sobering statistics:

  • 210,000 to 440,000 people lose their lives each year to medical errors in hospitals, according to research conducted by J. James and published in the Journal of Patient Safety.
  • Medical errors may now rank as the third leading cause of death in the United States; only cardiovascular disease and cancer takes more lives each year.
  • Preventable Adverse Events (PAEs) account for “roughly one-sixth of all deaths that occur in the U.S. each year.
  • More than 1,000 people die every day from preventable accidents in hospitals.
  • Preventable medical errors, in the form of “oops”, errors of omission, complications, readmissions, and avoidable mortality cost the US economy untold billions each year.
  • The average hospitalized patient experiences 1.5 medication errors daily and medication errors are the most common form of error.
  • There are more than 6 million patient injuries per year due to errors.
  • 40 percent of hospitals received a C, D, or F on Leapfrog’s Safety Score.
  • According to the Leapfrog Group, “since Fall 2014, (hospital) performance on safety outcomes – including preventing errors, accidents, and infections – has not significantly improved.”

How The Board Quality Committee Drives Quality

Here is an excerpt from an article I wrote in hfm, the journal of the Healthcare Financial Management Association. It has some great tips to help the effectiveness of your Board Quality Committee.

Board Quality Committee

“In today’s healthcare environment, every hospital or health system board committee should play a role in enhancing value. Given the direct relationship between better quality and lower costs, the board quality committee can provide strategic oversight for quality improvements that also boost the bottom line.

Here are five proven approaches to putting the board quality committee in a position to improve not only quality performance, but also financial outcomes.”

More …

Click here for a copy of the entire article.

Surgeon Complication Rates Now Posted on the Internet

Information on Physician Performance is Here to Stay

Patient complication rates have been posted on the Internet for almost 17,000 surgeons. This landmark undertaking was achieved by ProPublica, an independent, non-profit newsroom[1].

ProPublica posted their “Surgeon Scorecard” in July. It compares the performance of surgeons for eight common elective procedures, including hip and knee replacements, spinal fusions, gallbladder removals, prostate resections, prostate removals, and cervical fusions.

The power of ProPublica’s site was demonstrated to me this morning when my brother sent me a text message that said, “Kathy (his wife) is having her knee replacement this morning.” I immediately asked for the surgeon’s name and then looked up his stats on ProPublica’s new site. In less than 5 minutes, I had information that would have previously taken hours, if not days, of phone calls to colleagues and professional acquaintances for recommendations and best guesses about who would be best for my sister-in-law to see.

6 Steps to Physician Engagement

The KEY to GREAT QUALITY

An excerpt from my article on Physician Engagement:

SOME OF THE MOST SUCCESSFUL QUALITY leaders are those who have mastered physician engagement. But working with physicians in a positive and collaborative manner eludes many health care and physician leaders.

I’m not sure why, but whatever the reason, physician engagement is critical to your success as a quality leader. Your ability to partner with your colleagues in a collaborative, collegial, respectful and honest way spells the difference between creating great quality programs or mediocre ones. This is because physicians influence 85 percent of patient outcomes due to the decisions they make and the orders they write.

In the attached article I wrote in the March/April issue of the Physician Leadership Journal, I review some of the most important aspects of physician culture, especially how you can leverage this knowledge to dramatically improve engagement. When physician engagement is ideal, your quality and safety programs will experience even more success.

To access The 6 Steps to Physician Engagement and a pdf of the article, click on this title: GREAT PHYSICIAN ENGAGEMENT IS KEY TO GREAT QUALITY.

Question: What approaches have you used to partner with physicians? 

Sentinel Event Alert Issued

The Joint Commission Issued an Important Sentinel Event Alert Yesterday.

The safe use of information technology and electronic health records (EHRs) is the focus of a new Sentinel Event Alert (SEA) issued today by The Joint Commission (TJC). TJC analyzed 3,375 sentinel events from January 2, 2010 through June 30, 2013.

Simple Ways To Prevent Devastating Errors

Over the years, I’ve learned that safety science can be a complex topic.

And you know what I mean…we all hear of the terms high reliability, high reliability organizations, safety culture transformation, just culture, and crew resource management, just to name a few.

Sterile Cockpit Rule

Sterile Cockpit Rule

But making things too difficult impedes adoption and perhaps, this is one reason why we haven’t made the progress that we need to eliminate harmful errors.