AHA Attacks Medication Safety Problem

The American Hospital Association (AHA) has enlisted the aid of the Institute for Safe Medication Practices (ISMP) of Huntington, PA, to help hospitals examine and further improve medication safety to reduce drug-related errors.

AHA president Dick Davidson announced the new initiative during a December 7 White House briefing, the same day President Bill Clinton made public his plans for a federal campaign to combat medical errors. A recent report by the Institute of Medicine placed the issue of medication errors in hospitals under close scrutiny by stating that 44,000 to 98,000 Americans die each year as a result of the errors.

As part of the AHA effort, the ISMP will provide hospital leaders with an inventory of successful practices for reducing errors. The practices are based on the work of experts and organizations that study medication safety and can be adopted in every hospital.

The AHA and the ISMP developed a self-assessment tool, the "Medication Safety Awareness Test," designed to help hospitals check and track medication safety efforts and demonstrate progress on error prevention. The two groups also plan to develop a non-punitive medication error reporting process.

Also on December 7, the AHA sent a Quality Advisory to all its member hospitals urging executives and trustees to make safety a specific priority. In the advisory, Davidson suggested that hospitals review their policies and procedures for reporting and investigating errors, placing an emphasis on the need to correct the problems that lead to mistakes rather than passing blame for them.

The Quality Advisory was re-issued to all hospitals in mid-February, along with a confidential medical safety questionnaire.

Some of the short-term fixes hospitals might implement, according to the advisory, include: implementing a unit-dose system for all non-emergency drugs, with necessary dose adjustments for children, older adults, and patients with certain conditions; limiting the variety of devices and equipment used in administering drugs, such as general purpose infusion pumps; and creating special procedures and written protocols for high-alert drugs.

In the long term, hospitals should plan to increase the use of computers in drug administration systems. Computers can be useful for generating records, profiling in pharmacies, and implementing the use of bar codes for administering medications.

Prescriptions for Safety

Specific, immediate steps can reduce drug errors-with support from senior hospital managers and trustees. An American Hospital Association (AHA) advisory issued to all hospital CEOs offers ideas for quick fixes and longer-term solutions to hospitals' huge drug error problems.

After reviewing information culled from 11 organizations working on patient safety, the AHA suggested that hospitals could easily:

• Implement unit dose systems for all non-emergency drugs and stress necessary dose adjustment for children, older adults and patients with certain conditions.
• Limit the variety of devices and equipment used in administering drugs, such as general purpose infusion pumps.
• Create special procedures and written protocols for high-alert drugs. For instance, hospitals can consider removing concentrated potassium chloride/phosphate from floor stock and limit the number of possible concentrations for dangerous drugs.
• Make sure medical staff has new drug information by distributing newsletters or having pharmacists make rounds with physicians and nurses. Distribute drug error information from outside organizations.
• Consider the error potential in all new products before approving their use.
• Tell patients how to use their medications safely at discharge and encourage questions. In outpatient settings, inform patient what they are taking, why and how to use it safely. Urge providers to seek pharmacists' help with patients who are discharged on more than five drugs.
• Make pharmacists available. Hospitals that don't operate 24-hour pharmacies should have pharmacists on call.
• Communicate carefully. Avoid dangerous abbreviations. Make sure drug orders include dose, strength, units, route, frequency, and rate; and use only the metric system and drugs' full names.
• Standardize processes, including doses, times of administration, packaging and labeling, storage, dosing scales, and procedures for using and storing high-alert drugs.

Substantial changes require a long-term plan. The AHA recommends these costlier steps:

• Develop a voluntary system to monitor and report adverse drug events. Reporting will increase if employees don't fear reprisal.
• Increase use of computers in drug administration systems. Use computer-generated or electronic drug administration records and computerize drug profiling in pharmacies. Consider using bar coding for administering drugs.
• Encourage vendors to help place a system of checks into computerized pharmacy systems-like screens for duplicate drug therapies, patient allergies, and potential interactions and dose ranges.
• If possible, have a 24-hour pharmacy; or use night formularies and careful drug selection and storage procedures. Make pharmacist consults available when they aren't onsite.

High-Alert Medications And Patient Safety

Results of a recent study conducted by the Institute for Safe Medication Practices (ISMP) to determine the drugs and situations most likely to cause harm to patients showed that a majority of medication errors resulting in death or serious injury were caused by a specific list of medications.

Drugs having the highest risk of causing injury when misused are known as high-alert medications. The top five high-alert medications identified by the ISMP study are insulin; opiates and narcotics; injectable potassium chloride (or phosphate) concentrate; intravenous anticoagulants (heparin); and sodium chloride solutions above 0.9%.

Insulin

• Lack of dose check systems
• Do not store insulin and heparin vials near one another on a nursing unit
• Spell out the word "units" instead of using the abbreviation "U" (which can be confused with "O," resulting in a 10-fold overdose)
• Incorrect rates being programmed into an infusion pump

Opiates and Narcotics

• Parenteral narcotics should not be stored in nursing areas as floor stock
• Alert staff about confusion between hydromorphine and morphine
• Patient-controlled analgesia (PCA) errors regarding concentration and rate
• Limit the amount of opiates and narcotics in the floor stock

Injectable Potassium Chloride or Phosphate Concentrate

• Do not store concentrated potassium chloride/phosphate outside of the pharmacy
• Use commercially available premixed IV solutions
• Be wary of requests for unusual concentrations

Intravenous Anticoagulants (Heparin)

• Unclear labeling regarding concentration and total volume
• Multi-dose containers
• Confusion between heparin and insulin due to similar measurement units and proximity

Sodium Chloride Solutions above 0.9%

• Remove sodium chloride solutions (above 0.9%) from nursing units
• Standardize and limit drug concentrations/formulations
• No double check system in place

Physician Handwriting Skills Need Improvement

A recent Institute of Medicine report cites illegible handwriting as one cause for medical errors. Due to widespread media and governmental attention, experts predict that surveyors will check medical records more thoroughly to make sure physicians write legibly.

According to the February 2000 Briefings on JCAHO, legible handwriting is not only a medical records and patient safety issue, it is also a Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirement. Standard I.M.3.2.1 in the Management of Information chapter in the Comprehensive Accreditation Manual for Hospitals (CAMH) states that the review of medical records addresses the presence, timeliness, legibility, and authentication of the medical record. Standard MS.8.2.3 in the Medical Staff chapter of the CAMH states that the medical staff are expected to take a leadership role in determining whether a patient's medical records are accurate, timely, and legible.

Briefings on JCAHO mentions the following suggestions for tackling the problem of illegible handwriting:

• Catch bad handwriting early. Have your medical records committee monitor written progress notes, written orders and physician's signatures. Several individuals should examine each chart; all should be able to read it.
• Standard hospital policy. Legible handwriting should be a criterion for appointment for new physicians.
• Introduce a computer entry system. By using a password, physicians can type in an order at a computer terminal and send the order to a printer in the area where they want the order sent. As long as they provide the password, the JCAHO considers this to be a signature.
• Keep an eye on quality. Monitoring the quality of documentation should be a part of your ongoing record review, a process the JCAHO requires.

Hospitals Not Prepared for Terrorists

The threat of a large-scale terrorist attack involving chemical or biological agents is significant, but hospitals and healthcare workers are unprepared, according to an article in the January 12 issue of the Journal of the American Medical Association.

Existing hospital plans for responding to accidental exposures to hazardous materials would be inadequate in the aftermath of a terrorist attack, researchers said. They suggested hospitals better protect staff and coordinate with outside emergency response teams. Researchers also advised that hospitals publicize information about contaminant risks in addition to caring for the injured.

In the spring, the American Hospital Association plans through sponsorship of the HHS' Office of Emergency Preparedness to conduct an invitational forum to discuss hospital preparedness. The JAMA article is at http://jama.ama-assn.org/#2000.

ACHE Category I Workshop

The Arkansas Hospital Association and the Arkansas Healthcare Executives Forum will cosponsor an ACHE workshop, "Advanced Negotiating," featuring Christopher Laubach, May 16-17, at the Holiday Inn Select in Little Rock. The workshop is approved for 12 Category I (ACHE) credits toward advancement and recertification in ACHE, and features:

• A review of the basic negotiation process, including five key elements for ensuring a successful agreement, and evaluation of negotiating styles.
• Elements necessary to an environment for successful negotiating, such as trust, recognition of needs, alignment of objectives, and conflict management.
• Advanced negotiation techniques, including the presentation of persuasive arguments, development of strong listening skills, creation of value-added partnerships, and treatment of non-negotiators and hard-ballers.
• Explanation of negotiation dynamics in a capitated marketplace.

Registration information about the workshop will be mailed in early March. Early registration is recommended, because the meeting is limited to 40 participants.

Arkansas Women Getting Breast Exams

According to the Arkansas Department of Health, women in the state are doing a better job at getting regular breast exams and mammograms. Among women age 40 and over, 57.5% report they have received a mammogram and clinical breast exam (CBE) within the last two years. That is up from 53.9% in 1996, and is the highest rate recorded in the six years the Health Department has tracked the exams.

Information provided by the department's Center for Health Statistics also showed the percentage of women 40 and older who have never had either a mammogram or CBE fell to 25.5% in 1998, the lowest figure for that rate. Data for the report was taken from the 1998 Arkansas Behavioral Risk Factor Surveillance System.

In 1997, the Arkansas General Assembly passed legislation which provides for screening, diagnosis, treatment, surveillance activities, and public and professional education for women in Arkansas, all of whom are at risk for developing breast cancer. The disease killed 383 people in Arkansas last year, including two men.

Flu Pandemic Possible

In cooperation with the U.S. Centers for Disease Control and Prevention (CDC), the Arkansas Department of Health has begun preparations for a potentially deadly, global flu outbreak expected to occur within the next 50 years. The CDC has urged all states to develop contingency plans for the possible outbreak, which could be similar to flu pandemics which occurred in 1918, 1957, and 1968. The 1918 pandemic killed 20 million people worldwide.

According to the CDC, the following information will explain the anticipated course of an influenza pandemic:

• There will be a five-month warning period of a coming pandemic. (Five months will elapse from the time that a new strain of influenza virus is identified until the influenza causes a worldwide pandemic. During that time, a vaccine is likely to be developed and production will begin.)
• Two waves of the pandemic will affect each state. The second wave will strike approximately six months after the first.
• The first wave will have the following affects:
• Influenza affects 25% of the population
• An overall case-to-hospitalization rate of 4% will occur
• Fatalities of those who contract the virus will be 1.7%
• The second wave will have the following affects:
• Influenza affects 5% of the population
• An overall case-to-hospitalization rate of 4% will occur
• Fatalities of those who contract the virus will be 1.7%
• Each wave will last about one month and peak at two weeks.
• No vaccine will be available until one month before the U.S. pandemic.
• The vaccine supply will initially cover 20% of the population, and will increase monthly. Therefore, there will not be enough vaccine for the entire population.

According to "The Economic Impact of Pandemic Influenza in the U.S.: Priorities for Intervention," in the September-October 1999 Emerging Infectious Diseases Journal, the authors estimate the next influenza pandemic in the U.S. will cause 89,000 to 207,000 deaths; 314,000-734,000 hospitalizations; 18-42 million outpatient visits; and 20-47 million additional illnesses. The estimated economic impact would be $71.3-$166.5 billion, excluding disruptions to commerce and society.

For more information about the influenza pandemic and its impact in Arkansas, call Dr. Sandra Snow, medical epidemiologist, Arkansas Department of Health, at 501-662-2169, or e-mail her at slsnow@mail.doh.state.ar.us.

Arkansas Hometown Health Projects

Last year, the Arkansas Department of Health implemented a pilot Hometown Health Improvement Project (HHIP) in Boone County. The HHIP is a community-driven project designed by the Health Department to help local areas address their own unique healthcare needs.

The project is geared to allow the department to help communities identify where problems exist, develop and carry out plans that will allow them to resolve those problems, bring together healthcare and community leaders in partnerships that can provide needed resources and measure progress to show solutions are paying off.

Ideally, results will include reduced healthcare costs, a decrease in workplace and school absences related to illness, and improvement in social problems such as teen pregnancy and drinking, and child abuse.

Dr. Fay Boozman, director of the Health Department, has announced the Boone County pilot program has made such significant progress that the project will be expanded into Polk, Scott, Montgomery, Union, Pike, Baxter, Washington, Crittenden, and Fulton counties.

Central Arkansas VA
Participates In Clinical Trial

Cardiology researchers at the Central Arkansas Veterans Healthcare System (CAVHS) announced that they are participating in a national clinical trial to evaluate a new non-invasive treatment for patients with claudication (leg muscle pain brought on by walking and relieved by rest) due to peripheral artery disease (PAD). The compound, called fibroblast growth factor (FAF-2) is a recombinant form of a naturally occurring protein that has been shown to sitmulate cell and blood vessel growth in preclinical studies.

The Phase II clinical trial is intended to evaluate the efficacy and safety of FGF-2 in patients with moderate to severe claudication due to PAD. Patients enrolled in the study are followed for six months to measure changes in their exercise capacity and quality of life. In addition, changes in peripheral blood flow are measured at some centers. The study is being conducted by a newly formed group of physicians, the Peripheral Atherosclerosis Research Consortium (PARC). There are 22 medical facilities in the U.S. currently participating in the Phase II clinical trial. Reasons cited for the selection of CAVHS as a participant include the excellence of research done in other studies, as well as the quality and volume of clinical practice by the institution's physicians.

The Central Arkansas Veterans Healthcare System, a flagship Department of Veterans Affairs healthcare provider, is one of the largest and busiest VA medical centers in the country. Its two hospitals, located in Little Rock and North Little Rock, anchor a broad spectrum of inpatient and outpatient healthcare services, ranging from disease prevention through primary care, to complex surgical procedures, to extended rehabilitative care.