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To prevent ordering errors, one hospital is bringing “read backs” to the bedside

October 2006

Published in the October 2006 issue of Today’s Hospitalist

As hospitals around the country adopt “read-back” strategies to prevent errors, one medical center has brought the technique to the bedside during rounds.

Read backs are not particularly new. A staple of the military and the aviation industry, the technique is being increasingly used to guard against miscommunication when medical orders are relayed over the phone. But the strategy received a big boost a few years ago when the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) put read backs on its list of patient safety goals.

The agency said that whenever a verbal order is made, who ever is on the receiving end “whether that’s a nurse or physician “must first document the order and then read it back to ensure its accuracy. The goal is to make sure information is accurate when it has been documented, either on a paper chart or in a computer system, to prevent errors.

While hospitals around the country have been implementing read-back strategies to meet JCAHO regulations, Cincinnati Children’s Hospital Medical Center has taken the technique a step farther. Along with requiring staff to use read backs during telephone calls and other forms of non-face-to face communication, the hospital is applying read backs to orders made at the point of care.

Going wireless
When Cincinnati Children’s first began using read backs to improve the accuracy of phone orders between physicians and nurses, someone had a great idea: Why not use the strategy to avoid errors during rounds?

The technique had the potential to work because of the way the hospital uses technology. Cincinnati Children’s not only has a computerized physician order-entry system (CPOE), but the entire hospital complex is wireless.

As a result, when physician teams round, they usually work on a laptop computer that’s attached to a cart. Interns typically enter orders for tests and medications into the hospital’s CPOE system, so all orders are finalized by the time the team leaves the patient’s room.

Because the information being transmitted from the team to the intern using the laptop is essentially a verbal order, the thinking went, why not subject it to a read back?

“If we’re in a room and a resident says, ‘Let’s change this medicine to ceftriaxone at 250 milligrams every 12 hours,’ that’s really a verbal order,” explains Michael Vossmeyer, MD, who led the initial testing and implementation of read backs during rounds.

Eliminating errors
Intrigued by the suggestion, Dr. Vossmeyer and his colleagues first examined the orders entered at bedside for 70 patients.

To their surprise, they found some sort of error in just over 9 percent of those orders. Most were dosage errors or problems with prescribing intervals, but two were orders for the wrong drug.

Based on those data, Dr. Vossmeyer spearheaded an effort to implement read backs during rounds on a general pediatrics nursing unit. Before rounding teams left a patient’s room in that unit, the intern charged with entering orders into the wireless system would read them back to make sure they were accurate. The attending physician or senior resident would then verify that the orders were in fact correct.

“It gives the attending and the senior resident and the rest of the team a chance to say, ‘This is the correct order, it’s the dose we agreed on,’ ” explains Dr. Vossmeyer, who is assistant professor of clinical pediatrics and medical director of the general inpatient hospital service at Children’s. “We read back every order that’s entered.”

The results were impressive. When Dr. Vossmeyer’s team looked at a second round of patient orders, they found that there was not one single error.

While he acknowledges that the before-and-after methodology his team used to track errors may be relatively unsophisticated, Dr. Vossmeyer explains that the goal was to find a “quick-and-dirty” quality improvement project that would help the hospital improve safety without requiring a massive investment of time or money.

While read backs produce excellent results, he points out, they cost almost nothing “and they add only a few seconds to the daily duties of rounding teams.

Broad applicability
If read backs seem like a technique that will work only at hospitals like Cincinnati Children’s that are flush with computer technology, think again. Dr. Vossmeyer says that even lower tech facilities can take advantage of read backs, particularly teaching hospitals that have housestaff acting as scribes for the rounding team.

Even if orders aren’t being entered electronically at the bedside, he explains, someone like an intern is usually taking notes for the team and entering orders into a computer system or patient charts later.

“In these instances, there’s still no check in terms of going back and reviewing what is written down,” Dr. Vossmeyer says. “Read backs provide an excellent opportunity to make sure that what we discussed is actually going to be put into the system.” In fact, the technique should be used “any time you’re passing information to someone else verbally and that information has the potential to create patient harm.”

According to Dr. Vossmeyer, the hospital continues to fine tune its use of the technique.

There are, for example, issues of reliability: Someone has to remember to prompt the team to do a read back before they leave the room. Dr. Vossmeyer says that research has shown that even in the best of circumstances, people generally remember to implement a needed step only 85 percent to 9 0percent of the time.

“If the senior resident forgets,” he says, “it could potentially not get done, and you could have errors.”

He adds that ideally, the hospital will incorporate reminders for staff to conduct read backs into its electronic systems.

Expanded uses
Since Dr. Vossmeyer’s team first studied the use of read backs, the hospital has begun to expand the technique beyond the general pediatric ward where it was introduced.

The gastroenterology team is now using the read back system, Dr. Vossmeyer says. Because the medications used in that unit are so much more critical, the stakes are even higher in preventing errors.

While the obvious success of the read-back strategy has been in reducing errors, Dr. Vossmeyer says the initiative is also important because it shows how decidedly low-tech interventions can be successful “even in an environment like Children’s, which has implemented state-of-the-art systems.

“We talk about CPOE, which is good,” he explains, “but there are errors made from what you hear and what you perceive is being said, not just the sexy problems like drug-drug interactions. Any process that creates redundancy in looking for errors increases patient safety.”

Edward Doyle is Editor of Today’s Hospitalist.