Published in the August 2008 issue of Today’s Hospitalist
IF YOU COULD REPORT adverse drug events quickly and easily on a handheld computer, would you be more willing to report those events “even if you were at fault? A new study concluded that the answer is “yes,” but with some important caveats.
The study, which appeared in the April 2008 issue of Journal of General Internal Medicine, found that giving physicians and nurses handhelds led to an increase in their voluntary reporting of adverse drug events. But researchers noted that there are still some critical issues that must be resolved before error reporting goes digital.
Questions remain, for example, about how to make sure data on events remain secure and how widely handheld technology will be adopted. But while it may be another year or two before handhelds enter the mainstream as a reporting device, researchers see the technology as part of a suite of computer-based tools that will increasingly supplant paper-based reporting.
Here’s a look at what researchers found that makes them confident that handhelds “as a way to track inpatient drug problems “may well be a part of your future.
A culture of reporting
The status quo for event reporting is for physicians and nurses to fill out a paper form. As proof of just how broken current error reporting systems are, experts say that only 0.04% of adverse events in hospitals are currently being reported.
That led researchers to look at how technology could improve reporting rates and provide a better handle on how and why events occur. Adrian W. Dollarhide, MD, an internist at the VA San Diego Healthcare System and the study’s lead investigator, enlisted a programmer to create a medication event reporting tool for the Palm Zire 21 handheld. Dr. Dollarhide and his colleagues then gave the device to 185 physicians and 119 nurse volunteers from four university-affiliated hospitals to use for one-week intervals.
The handhelds would beep every 90 minutes to remind participants to enter data about their clinical work and to report any recent adverse drug events. A survey tool that was part of the software collected details on adverse events and near misses, asking participants the following questions: What was the outcome of this event? What medication was involved? What causes “such as communication, equipment, devices and other clinicians “contributed to the event?
Participants were also asked to rank their own involvement in the event, ranging from being completely responsible to not at all. While that might seem controversial, Dr. Dollarhide says the primary objective was to focus on systems issues, not finger pointing.
“The challenge is to foster a culture of reporting that gets to the root of system or practice issues that affect safety,” he says.
Each report took between three and five minutes to complete. Because the software used intuitive pick lists based on already existing paper forms, no additional training was needed. The results? Participants reported 76 events over the course of 2,311 clinician shifts. Dr. Dollarhide points out that the rate represents a 15-fold increase over previous reporting at one of the participating hospitals, which had been using typical reporting mechanisms.
Nurse vs. physician reports
“We captured events “particularly near misses “that hadn’t been reported before,” says Timothy R. Dresselhaus, MD, MPH, another study author and associate chief of the San Diego VA medicine service.
Nurses used the handhelds more than physicians in the study, a result that didn’t come as a surprise. (Nurses historically do more event reporting, regardless of the reporting mechanism.) Their rate was 0.045 reports per shift vs. 0.026 reports per shift per physician.
However, attending physicians had a similar rate “0.042 reports per shift “as nurses. Dr. Dollarhide explains that the difference in the overall physician reporting rates may have been due to one of the study’s more unexpected findings: less participation by residents. While conventional wisdom says that younger clinicians are more inclined to use technology, he says, the reality is that busy residents had less time to use the tool.
Lower reporting rates don’t necessarily mean, Dr. Dollarhide adds, that physicians are unwilling to fess up to problems with patients. Instead, the results may be an indicator of the different workloads that nurses and physicians carry. Nurses, for example, tended to report more near misses related to medication administration, while physicians were more likely to report problems in prescribing or ordering.
Could it work?
One good piece of news from the study is that integrating handhelds into error reporting systems is not necessarily a burden. The majority of participants reported no events and thus faced no time constraints.
Nevertheless, Dr. Dresselhaus points out, handheld computers have their limits. “You wouldn’t want an alarm to go off every 90 minutes to ask about adverse drug events,” he says. The technology would work best, he adds, if it was readily available and issued only occasional prompts.
Still, a portable system would be a huge improvement over today’s mix of volunteer systems that rely on either paper reporting or on fixed computer workstations scattered around the hospital. Portable reporting software would be “particularly attractive,” says Dr. Dresselhaus, “if it was bundled with other applications, such as patient databases or decision-support tools.”
He also notes that adopting handheld reporting technology may be more realistic for academic centers than for community hospitals with fewer resources. While the handhelds used in the study cost about $150 each, hospitals also need the ability to develop or fine-tune software to collect data, and expertise for data analysis.
The end of paper reporting
Another challenge is ensuring that data stay secure when they are downloaded from the PDA. In the study, data were downloaded at each site with cables directly into a server. While users initially could be identified, they were each “de-identified” at the point of collection.
But the bottom line, says Dr. Dollarhide, is that the results were persuasive enough that he sees a time not so far in the future where hospitalists and residents who come on staff won’t have to bring their own PDAs. Instead, they will be handed a device with software based on either formularies or drug-drug interactions bundled with reporting software.
“Paper forms for adverse event reporting will uniformly disappear,” Dr. Dollarhide predicts. “We are so bad at reporting events that we really owe it to ourselves to design better systems.”
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.