THE ISSUE: Experts say there are many different factors that lead to medical errors. Steps have been taken at hospitals across the country to address the issue, but some are making patient safety number one on their list of priorities. Of the more than 6,000 hospitals in the United States, two facilities have gone beyond the requirements and have made a difference in the healthcare system.
CASE 1 - THE VA: Jim Bagian, M.D., is the director of the VA's National Center for Patient Safety. The center tracks medical errors and close calls, which Dr. Bagian says is vital.
"Since close calls happen anywhere from 20 to 600 times more commonly than the actual event that could occur, that gives you all those times to learn the easy way," Bagian said.
He says the motivation for people to report medical mistakes and those near misses is the VA's blame-free culture.
"I call fault the "F" word of medicine. Instead of saying whose fault is it, it's about saying, 'What happened? Why did it happen and what do we do to prevent it?" asked Bagian.
The VA center in Topeka, Kansas, has led the way in patient safety. There, nurse Sue Kinnick came up with the idea of bar-coding medications after watching a rental car company's system of tracking cars across the country.
Patients receive a bar-coded wristband as they enter the hospital, which is matched to the drugs they will be receiving - these are also bar-coded. Nurses scan both before a medication is given. A mis-match prompts an alert and saves the patient from receiving the wrong medication or the wrong dose at the wrong time.
While it started at the Topeka VA, the bar-coding system has since become a nationwide requirement for VA hospitals.
"The prototype with over eight million doses dispensed had prevented over 549,000 medication errors. Without that alert from the computerization, those medication would have been administered and those errors would have occurred," said Russell Carlson, R.N., and functional analyst for the VA in Topeka.
CASE 2 - MISSOURI BAPTIST MEDICAL CENTER: In 2002, the American Hospital Association awarded its first-ever "Quest for Quality" prize to Missouri Baptist Medical Center in St. Louis. The award was given to the hospital in the United States that has done the most to advance a culture of patient safety. Patient safety and quality care has been an important part of the hospital's mission for years.
One of the most important steps in improving care was the appointment of a full-time patient safety specialist: Nancy Kimmel. She focuses on developing and implementing programs such as the hospital's patient safety hotline.
The hotline averages about 200 calls a month fielding calls and concern from staff on a wide range of safety issues. The calls are followed up with a newsletter called, "We Heard You, We Acted," which details what steps have been taken to address the specific issues that callers have.
The hospital also has a program called, "Mind Your Meds." It features a brochure with a tear-off, wallet-sized card for patients to keep track of their prescriptions. By showing the card to their doctors, the hope is that harmful drug interactions will be prevented.
Another innovative program addresses physician handwriting. Specialists send an education letter for physicians and mail it to them with a copy of the actual prescription that they wrote. In addition, an interactive box highlights samples of doctors' handwriting and uses them as an educational tool. Doctors answer questions regarding actual prescriptions that have been written by doctors in their hospital.
The programs in place seem to be working. The hospital has only spent about $100,000 and harm caused to patients as a result of errors has dropped 75 percent.
FOR MORE INFORMATION, PLEASE CONTACT:
Joe Murphy, APR
Public Affairs Officer
VA National Center for Patient Safety
Ann Arbor, MI
Communications/Media Relations Manager
Missouri Baptist Medical Center
3015 N. Ballas Road
St. Louis, MO 63131