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Patient Safety

Patient Safety

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Patient Safety

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  1. Patient Safety • Patient safety and reducing medical error has always been a top priority • Institute of Medicine Report 1999 • “More people die from medical errors each year than from suicides, highway accidents, breast cancer, or AIDS” • 44,000 - 98,000 deaths per year

  2. Medical Error Causes Of Death In U.S. 1997 • Heart 726,974 • Cancer 539,577 • Stroke 159,791 • Lung 109,029 • Accidents 95,644 • Pneumonia 86,449 • Diabetes 62,636 • Medical Errors 44,000 CDC, IOM

  3. Medical Error Medication Error • A medical error that occurs during the medication use process

  4. Prevention of Medication Errors CPOE • Computerized Physician Order Entry reduces errors in medication ordering • 55% reduction in serious medication errors in a BWH study • No impact on administration, dispensing, and transcription errors

  5. Error Stage for Serious Medication Errors eMAR CPOE

  6. Medical Error Medication Error • A medical error that occurs during the medication use process • 1.4% of BWH admissions using CPOE • 92% minor • 8% serious • 7% potential (near miss) • 1% preventable = .001 % or 1/1000 admissions Bates, et al

  7. Administration Errors at BWH • Recent review of Jan-Mar BWH incident reports • Electronic MAR with bar-coding would have prevented 66% of medication-related incident reports • Incident reports are tip of the iceberg • Approximately 5% of true event rate

  8. Barcode Initiative • Electronic Medication Administration Record (eMAR) • Medications bar-coded in pharmacy • Patients bar-coded with wrist bands • Nurses ID’s Bar-coded • Nurses scan bar-codes to check and document medication administration

  9. The Safe Environment • Office for Patient Safety • Centralized Provider Credentialing • Options for Disruptive Physicians • Enhanced Route Cause Analysis • Standing Committees • Specific Task Forces • CCE

  10. Office for Patient Safety Facilitate adoption of preventative initiatives • CPOE • Reduces serious medical errors due to ordering by 55% • Medication reconciliation during handoffs • Smart Pumps • Reduces administration errors by ?? • Web-enabled Incident Reporting System • Electronic Medication Administration Record • Bar Code Technology reduces • Transcription / dispensing errors by 80% • Administration errors by ??

  11. Administration Errors at BWH eMAR • Review of incident reports demonstrated eMAR with barcoding would have prevented 66% of medication-related incident reports • Pharmacy study demonstrated eMAR with bar coding reduced dispensing errors by 80%

  12. BWH eMAR Timeline • Proposed 1999 • Design / Development June 2001 • Drug repackaging facility 2003 • Initial eMAR Pilot CWN 2004 • Rollout 2005 • Estimated Cost $10 M • BWH Staff 170

  13. The BWH Drug Repackaging Center

  14. Prevention of Medication Errors Impact of eMAR ? • Too soon to determine • But……….

  15. Effect of Barcode Technology on Different Types of Dispensing Errors 56% reduction* 71% reduction* 90% reduction* * p<0.001 (Chi-squared test)