Magazine article Drug Topics

Hospitals-VHA and VA Alike-Launch Programs to Cut Errors

Magazine article Drug Topics

Hospitals-VHA and VA Alike-Launch Programs to Cut Errors

Article excerpt

VHA Inc., a nationwide network of community-owned healthcare organizations and physicians, has launched error-reduction programs at more than 200 hospitals around the country.

"Safety hasn't been a hard sell since the Institute of Medicine report came out last year," said Nancy Wilson, M.D., medical director and vp. of clinical affairs for VHA Inc. And with the average adverse drug event costing $4,700, she added, "there's a solid business argument in favor of reducing medication errors."

VHA's program is called Clinical Advantage. It's a combination of evidence-based techniques such as strict protocols for insulin and heparin with ongoing mentoring and coaching from regional experts in medication systems and errors.

But not all hospitals attack medication errors systematically. Some institutions simply punish individuals who make mistakes. What they should be doing, according to some experts, is cleaning up processes that routinely guide pharmacists into making mistakes.

"We have to get past the issue of blaming individuals for problems in the system," said Kasey Thompson, director of the Center on Patient Safety at ASHP "There is no structure to say that anyone has to practice evidence-based medicine and follow realistic guidelines. Patient safety is not Job One in health care."

A 1999 report in the journal of the American Medical Association noted that simply putting a pharmacist in the intensive care unit cut medication errors by 66%. Rounding with physicians reduces errors from bad handwriting, unclear drug orders, and similar communication problems, explained Julie Morath, COO and v.p. of care delivery at Children's Hospitals and Clinics in Minneapolis.

Putting clinical pharmacists on unit-based care teams helped Children's win a Patient Safety Award (and $10,000) from the National Patient Safety Foundation earlier this year. "The award is a nice external reflection of what we're doing," Morath said. "We're looking at other steps to remove all medication errors from chemotherapy by creating a system that enforces good practices."

Children's is focusing on low-cost, low-tech interventions like reassigning staff hours and duties. Physicians and nurses now review every patient chart and recalculate chemotherapy orders the day before treatment. And they do it in a dedicated room with no phone calls or other distractions.

The hospital also cracked down on verbal drug orders. …

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