Medical Error Prevention in the Emergency Department Solutions for the Future Graham Billingham, MD The Second Mediterranean Emergency Medicine Congress

Medical Error Prevention in the Medical Error Prevention in the Emergency DepartmentEmergency Department Solutions for the Future Solutions for the Future

Graham Billingham, MD

The Second

Mediterranean Emergency Medicine Congress

Sitges/Barcelona, Spain

September 15, 2003

““I will do no harm”I will do no harm”Hippocratic OathHippocratic Oath

Medical error is the fifth leading cause of death in the United States. More people die from medical errors than from car accidents, breast cancer or AIDS.

The Institute of Medicine 1999

“Medication errors are one of the most common causes of avoidable harm to patients”

Joint Commission Report 1995

““To Err is Human”To Err is Human”

We have met the enemy and it is us Institute of Medicine Report 1999 The Public will not tolerate medical errorLeapfrog Group – payers will not tolerateJoint Commission – governmental mandateInstitute for Safe Medication PracticesOther industries have embraced information

technology, why haven’t we?

The TruthThe Truth 180,000 unnecessary US deaths per year 1.3 million injuries per year $ 8 billion increase in national health costs Cost- adds $4700 per hospital admission 1.4 medication errors for every hospital admission The largest cause of adverse events in hospitals is

Adverse Drug Events (ADEs) which occur at the alarming rate of 65 per 1000 hospital admissions

60% may be preventable

Source: NCVHS Data

Adverse Drug EventsAdverse Drug EventsWho’s at fault?Who’s at fault?

Physician responsible – 56%Nurse responsible – 34%Secretary – 6%Pharmacy – 4%

Source: The Advisory Board

Common Physician IssuesCommon Physician Issues

Illegible signature – 78%Orders not timed – 58%Incomplete orders – 24%Illegible orders – 20%Other: too busy, distracted, verbal orders,

no checks and balances, rely on memory,

not aware of drug allergy or interaction

Common Nurse IssuesCommon Nurse Issues

Calculating dose– 80% incorrectly calculate 10% of the time– 40% make mistakes > 30% of the time

Administering the wrong medicineGiving medicine to the wrong patientFrequency errorsMissing doses

Medication ErrorsMedication ErrorsEffect on US MalpracticeEffect on US Malpractice

3% of total malpractice claimsAverage malpractice award = $636,000

Cost of ClaimsCost of Claims

Short term morbidity - anaphylaxis, respiratory failure, GI bleed

Long term morbidity - renal failure, anoxia, death

Difficult to defend because of “expert witness” (PDR/FDA indications)

Medical Errors- Root CausesMedical Errors- Root Causes

• Allergic reactions • Excessive dose• Incorrect drug given• Error in writing or reading Rx• Drug interaction • Failure to monitor drug levels or toxic

effects

Medical Errors – Medical Errors – Where do they occur?Where do they occur?

28% in ordering11% in transcribing10% in preparing51% in administering

JAMA 1996; 274-35-43

Why Do Errors Occur?Why Do Errors Occur?

• Time pressure/high patient volume• Failure to recognize high risk areas• Medication delivery system is complex• Multiple caregivers involved• Extensive medication knowledge base

Poor communication (verbal/written)• Lack of checks and balances system

Pitfalls In Medication Delivery Systems:Pitfalls In Medication Delivery Systems:

• Request for medication administration

• Nurse identifies correct medication & dosage

• Patient identified• Allergy ruled out• Medication

administered correctly

• Legible correct prescription

• Pre-printed instructions

• Pharmacist-patient communication

• Compliance

High Risk AreasHigh Risk Areas

Joint Commission (JCAHO)Joint Commission (JCAHO)

• Began tracking 1995• Medical Error Prevention Issue 1-1998• High Alert Medications Issue 11-1999• Sound-alike Drug Names Issue 19 -2001• Dangerous Abbreviations Issue 23- 2001

Root Causes of Medication Errors Root Causes of Medication Errors 1995-20021995-2002

Sentinel Event Trends: Sentinel Event Trends: Medication Errors (% of total)Medication Errors (% of total)

Medication Errors : High Risk Areas Medication Errors : High Risk Areas

High alert medications

High risk patientsHigh risk diseasesInfusion pumps

Verbal ordersAbbreviationsLook-alike drugsNo standardizationLack of automation

Medication Errors : High Risk Areas Medication Errors : High Risk Areas (JCAHO) High Alert Medications(JCAHO) High Alert Medications

Potassium ChlorideOpiates and narcoticsInsulin and oral hypoglycemic agentsAnticoagulants (Heparin)Antihypertensive agentsPsychiatric medicationAnticonvulsantsCardiac drugs

High Alert MedicationHigh Alert MedicationKCL ExampleKCL Example

Potasium Chloride• 10 incidents of death

– 8 from direct infusion– 6 cases KCL mistaken for another drug

- Heparin- Lasix- Saline flush

• Recommendation: must be stored and prepared in the pharmacy

High Risk Patients and DiseasesHigh Risk Patients and Diseases

PregnantElderlyHIVTransplant patientsAnticoagulantsAllergiesPediatric patientsPsych PatientsPatients on 2 or

more drugs

CHFHTNDiabetes Renal failureLiver failurePsych disorders

Medication Errors : High Risk AreasMedication Errors : High Risk AreasHigh Risk PatientsHigh Risk Patients

Pregnant Elderly HIV Transplant Patients Anticoagulants Allergies Psych Patients Patients on 2 or more

drugs

DigoxinCoumadinAspirinElavilHCTZEnalaprilZantacIndocinXanaxZithromax

Medication Errors : High Risk AreasMedication Errors : High Risk AreasHigh Risk PatientsHigh Risk Patients

Multiple Medications

2 medications = 13% chance of an ADI

7 medications = 87% chance of an ADI

DigoxinCoumadinAspirinElavilHCTZEnalaprilZantacIndocinXanaxZithromax

47% of patients discharged from the ED have a new medication added

Medication Errors : High Risk Areas Medication Errors : High Risk Areas PediatricsPediatrics

Medication Errors in a Pediatric Emergency Department. Medication Errors in a Pediatric Emergency Department. Selbst SM et al. Pediatr Emerg Care 1999Selbst SM et al. Pediatr Emerg Care 1999..

Incorrect Dose = 35% of errors Incorrect Medication given = 30% of errors Incorrect recording of weight Failure to note drug allergy

High Risk Areas: Infusion PumpsHigh Risk Areas: Infusion Pumps

Major Source of Medication Errors• High risk medications• Inadvertent free-flow• Incorrect pump programming• Calculation / concentration errors• Wrong medication

Case Study Case Study

30 y/o F history of post strep AGN s/p renal transplant. Presents with URI symptoms.

Meds : cyclosporin, Prednisone

Dx : bronchitis

A. Cipro

B. Zithromax

C. Erythromycin

D. Biaxin

Medication Errors: Medication Errors: Solutions for the EDSolutions for the ED

Recommendations/Summary

Give medication only if Give medication only if indicated – do no harmindicated – do no harm

Physician verifies PMHx, meds and allergies

Be aware of FDA/PDR recommendationsGive least toxic drug“Low and slow” ruleBe aware of high risk patientsBe aware of high risk medications

Medication RulesMedication Rules

Consider contraindications Consider drug interactions Consider adverse drug event Use bolus rather than infusion when available Monitor drug levels when appropriate Avoid prescribing medicine outside of the

scope of emergency medicine

Medication Errors: PreventionMedication Errors: PreventionDrug AdministrationDrug Administration

Infusion Pumps• Pumps with free-flow

protection• Standardize

– Medication use– # Of critical care drugs /

concentrations ( premix)

• Check system• Document dose calculation

on chart• Limit number of pump

types

“SMART” Infusion Pumps• Drug infusion protocol

library• Pre-defined dose limits• Automatic shut-off• Alarm system• Integrated Patient

Monitoring– Vital signs– Allergies– Age / Renal Function

The Future: Taking the Human The Future: Taking the Human Out of the ErrOut of the Err

• Reduce the reliance on memory• Pre-printed drug dosing protocols• PDA/bed side aides/wall charts• Automated drug dispensing• Standardize formulary• Automated drug calculator• Computerized Physician Order Entry• Clinical decision support• “Intelligent” EDIS


Use Pre- printed Protocols


Use Wall Charts


Use Bedside aides


Personal Digital Assistant


Automated Drug dosing and Distribution

Medication Errors: PreventionMedication Errors: PreventionImprove CommunicationImprove Communication

• Standardize Prescriptions“unit” vs. “u” 20U NPH for 200 NPH“every” vs. “q”“use leading zero, not a trailing zero”

– 0.4 not .40– 4 not 4.0– 2 ½ not 2.5


Patient– Dosage– Simplify regimen– 4 X day vs every 6 hours– Indication, side effect, duration– Pre-printed instructions– Include family


Medical staff• ID bracelets• Limit use of verbal orders• Beware of look alike/

sound alike• Call out system • Check System• Share plan with team


Caution with sound a likes / look a likesMgSO4 vs. MSO4Diprivan vs. DitropanNarcan vs. NorcuronNifedipine vs. Nicardipine vs. NimodipineBrevital vs. Brevibloc

Medication Errors: PreventionMedication Errors: PreventionInclude PharmacistInclude Pharmacist

Pharmacy Responsibilities Legible prescriptions• Controls all patient’s

medication• Checks for drug

interactions• Special Packaging• Provide information

sheet/Patient education

Medication Errors: PreventionMedication Errors: PreventionComputerized Physician Order Entry Computerized Physician Order Entry

(CPOE)(CPOE)

Benefits• Legible• Decreases number of hand-offs• No verbal orders• Guidelines displayed• Alternatives offered• Appropriate doses and frequencies• Built in alerts, allergies and interactions

Medication Errors: PreventionMedication Errors: PreventionComputerized Physician Order Entry Computerized Physician Order Entry

(CPOE)(CPOE)

Challenges• Changing behavior• Equipment availability• Equipment / software failure• Requires training• Orders entered on wrong patient • Cost

Computerized Physician Order Entry (CPOE) Computerized Physician Order Entry (CPOE)

Effect of CPOE on Prevention of Serious Medication Errors. Effect of CPOE on Prevention of Serious Medication Errors. Bates DW, JAMA 1998; 280: 1311-16Bates DW, JAMA 1998; 280: 1311-16

• Serious Medication Errors 55% • Decrease hospital LOS by one day• Decrease hospital charges by 13%• Adverse Drug Events

– Actual 17%– Potential 84%

The Role of Emergency The Role of Emergency Department Information Systems Department Information Systems

(EDIS)(EDIS)Passive tracking of patientsMedical error prevention tools built inImproves documentation and legibilityAutomates workflow – reduces hand-offsCQI tools for outcomes researchProvides clinical decision supportAutomates prescription writing

The FutureThe FutureBar code/RFID trackingDesign EDs around “Do no harm” principleStandardization of medications and processesAutomation of workflow and systemsCPOE becomes the new standard of careIntelligent EDIS with clinical decision supportPharmacy robotics and intelligent drugs

Final ThoughtFinal Thought

One thing is clear, our societies will not tolerate this rate of medical error, and neither should we. As it turns out, embracing information technology will be the easy part, changing human behavior will be the challenge of the future.

Web ResourcesWeb Resources

www.ismp.orgwww.nccmerp.orgwww.iom.eduwww.jcaho.orgwww.mederrors.comwww.advisoryboardcompany.com

Implementation of an EDISImplementation of an EDISA Case StudyA Case Study

Clifton A Sheets, MD, FAAEMMary Washington HospitalFredericksburg, VA USA

IntroductionIntroduction

Why an EDIS? Search Process Selection Process Implementation Impact Considerations

DisclosureDisclosure

A consultant for Patient Care Technology Systems Amelior ED®

Why an EDIS?Why an EDIS?

Process began in 1995– 300 bed Community hospital

Increasing ED patient volume– 60,000 annual visits in 1995– 87,000 annual visits (projected) in 2003

Increasing ED length of stayDecreasing patient satisfaction with ED

process strongly tied to LOS

Why an EDIS?Why an EDIS?

Paper/grease board/transcription – manual system – ineffective, and inefficient

Need for patient trackingNeed for automation of data collection and

processing

Driving forcesDriving forces

Community pressure to reduce time in ED US Compliance Issues JCAHO, EMTALA,

HIPAA Fundamental belief that CQI should be more

proactive Patient Safety

– Handwriting issues– IOM report 1999– Medication errors

Handwriting..Isordil or Plendil?Handwriting..Isordil or Plendil?

Driving forcesDriving forces

ED expansion planned for 2002– From 30 beds to 55

beds– From 13,000 sq ft to

27,000 sq ft

Search ProcessSearch Process

Needs identified– Streamlined patient care – Complete/compliant

documentation– Reduced transcription

costs– Enhanced patient safety

and error reduction– Optimized

reimbursement

Solutions identified– Patient tracking– CPOE– Nurse and physician

charting– Prescription writing– Discharge instructions


Collaborative effort– Physician champions identified (3)– Nursing and hospital administration– Administrative assistant– Ancillary services– Information Services– Medical records


Sources of information– EDIS trade shows and conferences– Electronic bulletin boards– Word of mouth– ED Physician group prior exposure

Selection ProcessSelection Process

Vendor’s RFP– Main players– Beware of “vaporware”

Best Few– Complete systems– Track record of success– Desired features

Site visit to “kick the tires”

Selection Process Selection Process

Selected “best 2” vendors with complete solutions (late 2000)

Site visits revealed problems such as incomplete system feature implementation and stability issues

Fear of failure

– Upfront cost– Physician use– Speed issues– Return on investment


Amelior ED® system identified as new vendor– Allergy and drug-drug interaction safety

features– Weight based dosing– Clinical decision support (protocols)– CPOE ease of use– Customization capability


Amelior ED®

– All-inclusive pricing based on patient volume

Key challenges– Beta site, no installations to visit– Unknown company with unknown resources– Hospital IS chief afraid of being stuck with a

legacy system, and no support

AAmelior melior EDED®®

Clinical features– Patient tracking– Nurse charting– Physician charting– CPOE– Prescription writing– Discharge instructions– Reports engine– Forms engine– Onsite user training

Technology– Microsoft®-centric– Bedside workstations– Additional nursing and

physician workstations– ADT, Lab, X-ray interfaces– 365 x 24 x 7 technical

support– Quarterly software

upgrades– Hardware refreshes

ImplementationImplementation

“big bang” vs phased approach Initial big bang in Nov 2001

– Lack of complete lab and x-ray interface capability– Speed and process issues resulted in a mutual

agreement to take the system down

Proof-of-concept in Fast track– Completed interface work– System turned on for rest of ED

Current StatusCurrent Status

Continuous operation since July 200190,000+ visits100% use by physicians and nursesBi-directional Interfaces:

– Lab orders and results– X-ray orders and interpretations– ADT information transfer– Lifetime clinical record

ImpactImpact

Decreased LOS by almost 1 hr in 1st 6 months– Volume has increased 14% this year

Eliminated handwriting issues– No more pharmacy call backs– Reduction in medication errors– Reduction in “missed” orders

Automated time stamp improved process analysis, accountability, and order execution times

ImpactImpact

Greatly enhanced ability to determine prior visit actions, results and treatments

Reduced “door to decision” timeStreamlined orders process

– Unit clerks eliminated from process– Improved protocol compliance

ImpactImpact

Nearly paperless ED– No “paper chase” for lab or X-ray results– No fighting over who gets the chart– No lost or misplaced charts

Improved transfer documentation – Instant chart for the transfer now available– Prompting for transfer (COBRA)

documentation

ImpactImpact

Financial– Reduced walk-outs by 57% (> $1 million annually)– 90% reduction in lines of transcription ($300k annual

savings)– Improved physician documentation

Increased RVUs– Length of laceration– Critical care time well documented

– Reduction in calls for medical records– Automated ICD-9, CPT and APC codes– Charge capture

ImpactImpactIncreased physician productivity = increased income

Average Physician RVU

2.05

2.15

2.2

1.95

2

2.05

2.1

2.15

2.2

2.25

2002 2003 YTD Jun-03

Impact Impact

Concerns– New technology introduces complexities

New users Data entry Safety feature bypass

ImpactImpact

Concerns– Different looking chart

Medical staff outcry over change– Small but vocal minority– Education on benefits– Modifications in font size appeased most– Paper chart made available for consultants

– Additional layers of regulation Passwords HIPAA rules specific to EMRs

SummarySummary

A full feature EDIS can– Reduce errors and improve patient safety– Eliminate handwriting issues– Improve workflow by reducing turn around

times for lab, x-ray and nursing orders– Improve data analysis and collection– Enhance hospital and physician revenues– Reduce length of stay

SummarySummary

Plan for an evolution and not a revolution Needs assessment drives the process Collaborative process Physician champions key to success Vendor environment is competitive and evolving Biggest may not be the best solution for your ED

Future of EDISFuture of EDIS

Bioterrorism monitoring and alertsProactive CQIEnhanced automationEmbedded digital imagingArtificial intelligenceMobile connectivity

““We have met future and We have met future and it is us”it is us”

Resources

Dr. Clifton Sheets [email protected]

Mary Washington Hospital www.medicorp.org

Patient Care Technology Systems www.pcts.com

EDIS Symposium www.paacep.org

AAEM www.aaem.org

ACEP Emergency Medical Informatics Subsection www.acep.org

Documents

Medical Error Prevention in the Emergency Department Solutions for the Future Graham Billingham, MD The Second Mediterranean Emergency Medicine Congress