Learning Experience

Article excerpt

Eight Utah hospitals find education program for providers can help reduce medical errors

Eight Utah hospitals reduced medication errors by 27% over a one-year period by using pharmacist, nurse, and physician education, said Michael Silver, health-care analyst with Salt Lake City-based Health-- Insight. He shared the eight hospitals' keys to improvement with attendees of the American Health Quality Association's 2000 Technical Conference, held in Orlando, Fla., in February.

HealthInsight, the Medicare Peer Review Organization (PRO) for Nevada and Utah, was contracted by the Healthcare Industry Group Purchasing Association to hold four semin over a period of a few months and assign exercises from the training to hospital staff. At the end of the seminars, more than 80% of the 560 staff members involved (396 nurses, 66 pharmacists, 46 physicians, and 52 "other staff") said they had implemented "substantive" systems changes that were expected to result in significantly improved patient safety. In addition to error reductions, errors that did occur were 13% more likely to be discovered and prevented from reaching the patient.

During the seminars and exercises, teams of nurses, pharmacists, and physicians were taught to identify problems in the hospitals' processes already in place, "based on their informed judgment." Using previous Harvard Medical School studies on medical errors and other sources as the bases, Silver knew that staff primarily needed education on several subjects. They include patient-identification procedures; how staff handles lethal drugs; hospitals' protocols for potential high-error medications, as well as preventing wrong doses and wrong medications; ordering drugs to which patients are allergic; and dispensing errors.

Over 40% of the teams found ordering errors, nearly 40% identified transcription mistakes, 40% found dispensing/delivery errors, and about 35% saw administration errors. "Many of these were prevented from reaching the patient, and very few actually injured the patient," Silver said.

After experts spoke to the seminar attendees and after colleagues shared war stories about their errors and prevention of errors in their facilities, the health professionals went to work. They improved medication-record layout, staff's access to drug and allergy information, and patient-identification methods. They also restricted physical access to potentially lethal drugs.

Many of the staff members simply needed to use the systems they already had in place more consistently. …