Published in the May 2005 issue of Today’s Hospitalist.
In the five years since the Institute of Medicine issued its landmark report on patient safety problems in American health care, U.S. hospitals have made inroads in how they handle, prescribe and dispense drugs to their patients. A new survey of hospitals now sheds some light on that progress and identifies areas where work still needs to be done.
About 30 percent of U.S. hospitals completed the survey, which was administered by the Institute for Safe Medication Practices (ISMP) in collaboration with the American Hospital Association and the Health Research and Educational Trust. The survey was funded by a grant from the Commonwealth Fund.
As part of a three-hour self-assessment, hospital administrators and a group that included physicians, nurses, pharmacists and risk managers provided information about their organization’s performance on a wide range of issues. Topics included how drug orders are communicated, what sort of redundancies and double-checks are regularly used on floors, and whether bedside bar-coding or computerized physician order entry is used.
Allen J. Vaida, PharmD, executive director of ISMP, says that hospitals reported a 20 percent to 40 percent improvement on the survey when compared to 2000, the last time the survey was conducted. As an example of that progress, he points to the portion of the survey that asks hospitals about whether they have “redundancies” in their systems to double-check drugs and doses ordered for particular patients.
On ISMP’s latest survey, hospitals scored 53 percent on questions that asked about processes of redundant systems to double-check drugs before they were given to patients. In 2000, by comparison, hospitals scored 41 percent in the same category.
Dr. Vaida says that the improvement hospitals showed in using redundant systems is typical of many of the results on the latest survey. While ISMP found significant improvement, he says, “There is still a long way to go.”
The ISMP’s self-assessment process found a 23 percent improvement in the number of hospitals that conduct patient education and actively involve patients in this education, but a significant number of hospitals are still doing relatively little in this area.
Dr. Vaida is quick to add that while the survey shows room for improvement, that may be in part due to the ambitious nature of many of the questions in the self-assessment process.
“We included a lot of stretch goals,” he says. “Some were innovative ideas. We wanted hospitals to start thinking about some of these processes, and to start thinking that if they were doing something in one area of the hospital, why weren’t they doing it everywhere.”
Dr. Vaida says that the survey shows that many hospitals “still have a way to go to bring the medical staff on board” with many of the process and system changes that have been shown to reduce drug errors.
As an example, he points to hospitals that try to institute formal policies to check the accuracy of verbal or telephone medication orders. While it may seem like common sense to require nurses who take verbal drug orders from physicians over the telephone to repeat the order back to make sure nothing gets lost in translation, Dr. Vaida explains that pushback from physicians can complicate matters.
“All too often,” he says, “physicians give an order and then automatically hang up or even chastise a nurse for repeating back an order. They sometimes even say they don’t have time for this.”
It’s an example of one opportunity that hospitals have to make progress in reducing drug problems. “There is a lot of evidence out there that things like this work,” he says. “Physicians should take the lead, and regularly say something like, ‘Read that back to me to make sure we have it correct.’ ”
Bringing physicians on board
Even as Dr. Vaida says that hospitals need to do more to reach out to physicians, he says it’s clear that many physicians understand the need to make changes in how they practice. A good example is avoiding abbreviations that have been shown to cause mix-ups.
If physicians weren’t on board with this type of initiative, he says, the recent survey would have shown much lower rates of improvement between 2000 and 2004. “You need everybody on board to show improvement in some of these areas,” Dr. Vaida explains. “It really is an interdisciplinary effect.”
Technology also appears to be contributing to hospitals’ improvements on the survey. The self-assessment found that nearly 15 percent of hospitals now have bedside bar coding processes in place for at least some of their patients. And about 12 percent of hospitals said they have computerized physician order entry, a number that is up 4 percent.
The ISMP survey found that the greatest improvements since 2004 occurred in hospitals’ willingness to discuss errors openly using nonpunitive approaches. ISMP found a 43 percent increase in “non-punitive, system-based approaches to error reduction.”
The recent survey also found a 29 percent improvement since 2000 in efforts to minimize problems with look-alike/sound-alike drugs. Many hospitals are now physically separating these drugs, putting alert stickers on them, or putting information in their computer systems that notify practitioners when these drugs are ordered.
The pace of progress
Dr. Vaida says that overall, he is encouraged by the pace of progress. He notes that as recently as 2000, in the aftermath of the IOM patient safety report’s publication, “many of these were new ideas. It is heartening to see that many hospitals now have adopted a much more open culture for sharing error reports.”
Another good sign? Dr. Vaida says that anecdotally, at least, hospitals that have conducted the self-assessment process that is part of the survey have said that it was “a great learning experience.” Many also use it as a jumping-off point for quality-improvement projects.
When they participate in the self-assessment process, he notes, physicians often learn that no hospital-wide sharing of error information exists. As a result of that realization, they often approach colleagues in other units to find, discuss “and learn from “their approach to reducing drug errors.
“All of a sudden,” Dr. Vaida says, “the nurses in med-surg are saying, ‘I never knew you guys were doing that. Maybe we should do it too.’ Or the physicians are saying, ‘You mean you don’t get automatic alerts on this?’ ”
Deborah Gesensway is a freelance writer who reports on U.S. health care from Toronto, Canada.