Medical Error Prevention in the Emergency Department Solutions for the Future Graham Billingham, MD The Second Mediterranean Emergency Medicine Congress Sitges/Barcelona, Spain September 15, 2003

“I will do no harm” Hippocratic Oath Medical error is the fifth leading cause of death in the United States. More people die from medical errors than from car accidents, breast cancer or AIDS. The Institute of Medicine 1999 “Medication errors are one of the most common causes of avoidable harm to patients” Joint Commission Report 1995

“To Err is Human” We have met the enemy and it is us Institute of Medicine Report 1999 The Public will not tolerate medical error Leapfrog Group – payers will not tolerate Joint Commission – governmental mandate Institute for Safe Medication Practices Other industries have embraced information technology, why haven’t we?

The Truth 180,000 unnecessary US deaths per year 1.3 million injuries per year $ 8 billion increase in national health costs Cost- adds $4700 per hospital admission 1.4 medication errors for every hospital admission The largest cause of adverse events in hospitals is Adverse Drug Events (ADEs) which occur at the alarming rate of 65 per 1000 hospital admissions 60% may be preventable Source: NCVHS Data

Adverse Drug Events Who’s at fault? Physician responsible – 56% Nurse responsible – 34% Secretary – 6% Pharmacy – 4% Source: The Advisory Board

Common Physician Issues Illegible signature – 78% Orders not timed – 58% Incomplete orders – 24% Illegible orders – 20% Other: too busy, distracted, verbal orders, no checks and balances, rely on memory, not aware of drug allergy or interaction

Common Nurse Issues Calculating dose Administering the wrong medicine 80% incorrectly calculate 10% of the time 40% make mistakes > 30% of the time Administering the wrong medicine Giving medicine to the wrong patient Frequency errors Missing doses

Medication Errors Effect on US Malpractice 3% of total malpractice claims Average malpractice award = $636,000

Cost of Claims Short term morbidity - anaphylaxis, respiratory failure, GI bleed Long term morbidity - renal failure, anoxia, death Difficult to defend because of “expert witness” (PDR/FDA indications)

Medical Errors- Root Causes Allergic reactions Excessive dose Incorrect drug given Error in writing or reading Rx Drug interaction Failure to monitor drug levels or toxic effects

Medical Errors – Where do they occur? 28% in ordering 11% in transcribing 10% in preparing 51% in administering JAMA 1996; 274-35-43

Why Do Errors Occur? Time pressure/high patient volume Failure to recognize high risk areas Medication delivery system is complex Multiple caregivers involved Extensive medication knowledge base Poor communication (verbal/written) Lack of checks and balances system

Pitfalls In Medication Delivery Systems: Request for medication administration Nurse identifies correct medication & dosage Patient identified Allergy ruled out Medication administered correctly Legible correct prescription Pre-printed instructions Pharmacist-patient communication Compliance

High Risk Areas

Joint Commission (JCAHO) Began tracking 1995 Medical Error Prevention Issue 1-1998 High Alert Medications Issue 11-1999 Sound-alike Drug Names Issue 19 -2001 Dangerous Abbreviations Issue 23- 2001

Root Causes of Medication Errors 1995-2002

Sentinel Event Trends: Medication Errors (% of total)

Medication Errors : High Risk Areas High alert medications High risk patients High risk diseases Infusion pumps Verbal orders Abbreviations Look-alike drugs No standardization Lack of automation

Medication Errors : High Risk Areas (JCAHO) High Alert Medications Potassium Chloride Opiates and narcotics Insulin and oral hypoglycemic agents Anticoagulants (Heparin) Antihypertensive agents Psychiatric medication Anticonvulsants Cardiac drugs

High Alert Medication KCL Example Potasium Chloride 10 incidents of death 8 from direct infusion 6 cases KCL mistaken for another drug Heparin Lasix Saline flush Recommendation: must be stored and prepared in the pharmacy

High Risk Patients and Diseases CHF HTN Diabetes Renal failure Liver failure Psych disorders Pregnant Elderly HIV Transplant patients Anticoagulants Allergies Pediatric patients Psych Patients Patients on 2 or more drugs

Medication Errors : High Risk Areas High Risk Patients Pregnant Elderly HIV Transplant Patients Anticoagulants Allergies Psych Patients Patients on 2 or more drugs Digoxin Coumadin Aspirin Elavil HCTZ Enalapril Zantac Indocin Xanax Zithromax

Medication Errors : High Risk Areas High Risk Patients Digoxin Coumadin Aspirin Elavil HCTZ Enalapril Zantac Indocin Xanax Zithromax Multiple Medications 2 medications = 13% chance of an ADI 7 medications = 87% chance of an ADI 47% of patients discharged from the ED have a new medication added

Medication Errors : High Risk Areas Pediatrics Medication Errors in a Pediatric Emergency Department. Selbst SM et al. Pediatr Emerg Care 1999. Incorrect Dose = 35% of errors Incorrect Medication given = 30% of errors Incorrect recording of weight Failure to note drug allergy

High Risk Areas: Infusion Pumps Major Source of Medication Errors High risk medications Inadvertent free-flow Incorrect pump programming Calculation / concentration errors Wrong medication

Case Study 30 y/o F history of post strep AGN s/p renal transplant. Presents with URI symptoms. Meds : cyclosporin, Prednisone Dx : bronchitis Cipro Zithromax Erythromycin Biaxin

Medication Errors: Solutions for the ED Recommendations/Summary

Give medication only if indicated – do no harm Physician verifies PMHx, meds and allergies Be aware of FDA/PDR recommendations Give least toxic drug “Low and slow” rule Be aware of high risk patients Be aware of high risk medications

Medication Rules Consider contraindications Consider drug interactions Consider adverse drug event Use bolus rather than infusion when available Monitor drug levels when appropriate Avoid prescribing medicine outside of the scope of emergency medicine

Medication Errors: Prevention Drug Administration Infusion Pumps Pumps with free-flow protection Standardize Medication use # Of critical care drugs / concentrations ( premix) Check system Document dose calculation on chart Limit number of pump types “SMART” Infusion Pumps Drug infusion protocol library Pre-defined dose limits Automatic shut-off Alarm system Integrated Patient Monitoring Vital signs Allergies Age / Renal Function

The Future: Taking the Human Out of the Err Reduce the reliance on memory Pre-printed drug dosing protocols PDA/bed side aides/wall charts Automated drug dispensing Standardize formulary Automated drug calculator Computerized Physician Order Entry Clinical decision support “Intelligent” EDIS

Medication Errors: Prevention Drug Administration Use Pre- printed Protocols

Medication Errors: Prevention Drug Administration Use Wall Charts

Medication Errors: Prevention Drug Administration Use Bedside aides

Medication Errors: Prevention Drug Administration Personal Digital Assistant

Medication Errors: Prevention Drug Administration Automated Drug dosing and Distribution

Medication Errors: Prevention Improve Communication Standardize Prescriptions “unit” vs. “u” 20U NPH for 200 NPH “every” vs. “q” “use leading zero, not a trailing zero” 0.4 not .40 4 not 4.0 2 ½ not 2.5

Medication Errors: Prevention Improve Communication Patient Dosage Simplify regimen 4 X day vs every 6 hours Indication, side effect, duration Pre-printed instructions Include family

Medication Errors: Prevention Improve Communication Medical staff ID bracelets Limit use of verbal orders Beware of look alike/ sound alike Call out system Check System Share plan with team

Medication Errors: Prevention Improve Communication Caution with sound a likes / look a likes MgSO4 vs. MSO4 Diprivan vs. Ditropan Narcan vs. Norcuron Nifedipine vs. Nicardipine vs. Nimodipine Brevital vs. Brevibloc

Medication Errors: Prevention Include Pharmacist Pharmacy Responsibilities Legible prescriptions Controls all patient’s medication Checks for drug interactions Special Packaging Provide information sheet/Patient education

Medication Errors: Prevention Computerized Physician Order Entry (CPOE) Benefits Legible Decreases number of hand-offs No verbal orders Guidelines displayed Alternatives offered Appropriate doses and frequencies Built in alerts, allergies and interactions

Medication Errors: Prevention Computerized Physician Order Entry (CPOE) Challenges Changing behavior Equipment availability Equipment / software failure Requires training Orders entered on wrong patient Cost

Serious Medication Errors 55% Decrease hospital LOS by one day Computerized Physician Order Entry (CPOE) Effect of CPOE on Prevention of Serious Medication Errors. Bates DW, JAMA 1998; 280: 1311-16 Serious Medication Errors 55% Decrease hospital LOS by one day Decrease hospital charges by 13% Adverse Drug Events Actual 17% Potential 84% Serious Medication errors decreased from 10.7 events/1000 patient days to 4.8 events /1000 patient days For a 500 bed hospital that’s 5 serious medication errors/ day to 2.5

The Role of Emergency Department Information Systems (EDIS) Passive tracking of patients Medical error prevention tools built in Improves documentation and legibility Automates workflow – reduces hand-offs CQI tools for outcomes research Provides clinical decision support Automates prescription writing

The Future Bar code/RFID tracking Design EDs around “Do no harm” principle Standardization of medications and processes Automation of workflow and systems CPOE becomes the new standard of care Intelligent EDIS with clinical decision support Pharmacy robotics and intelligent drugs

Final Thought One thing is clear, our societies will not tolerate this rate of medical error, and neither should we. As it turns out, embracing information technology will be the easy part, changing human behavior will be the challenge of the future.

Web Resources www.ismp.org www.nccmerp.org www.iom.edu www.jcaho.org www.mederrors.com www.advisoryboardcompany.com

Implementation of an EDIS A Case Study Clifton A Sheets, MD, FAAEM Mary Washington Hospital Fredericksburg, VA USA

Introduction Why an EDIS? Search Process Selection Process Implementation Impact Considerations

Disclosure A consultant for Patient Care Technology Systems Amelior ED®

Why an EDIS? Process began in 1995 Increasing ED patient volume 300 bed Community hospital Increasing ED patient volume 60,000 annual visits in 1995 87,000 annual visits (projected) in 2003 Increasing ED length of stay Decreasing patient satisfaction with ED process strongly tied to LOS

Why an EDIS? Paper/grease board/transcription manual system ineffective, and inefficient Need for patient tracking Need for automation of data collection and processing

Driving forces Community pressure to reduce time in ED US Compliance Issues JCAHO, EMTALA, HIPAA Fundamental belief that CQI should be more proactive Patient Safety Handwriting issues IOM report 1999 Medication errors

Handwriting..Isordil or Plendil?

Driving forces ED expansion planned for 2002 From 30 beds to 55 beds From 13,000 sq ft to 27,000 sq ft

Search Process Solutions identified Needs identified Streamlined patient care Complete/compliant documentation Reduced transcription costs Enhanced patient safety and error reduction Optimized reimbursement Solutions identified Patient tracking CPOE Nurse and physician charting Prescription writing Discharge instructions

Search Process Collaborative effort Physician champions identified (3) Nursing and hospital administration Administrative assistant Ancillary services Information Services Medical records

Search Process Sources of information EDIS trade shows and conferences Electronic bulletin boards Word of mouth ED Physician group prior exposure

Selection Process Vendor’s RFP Best Few Site visit to “kick the tires” Main players Beware of “vaporware” Best Few Complete systems Track record of success Desired features Site visit to “kick the tires”

Selection Process Selected “best 2” vendors with complete solutions (late 2000) Site visits revealed problems such as incomplete system feature implementation and stability issues Fear of failure Upfront cost Physician use Speed issues Return on investment

Selection Process Amelior ED® system identified as new vendor Allergy and drug-drug interaction safety features Weight based dosing Clinical decision support (protocols) CPOE ease of use Customization capability

Selection Process Amelior ED® Key challenges All-inclusive pricing based on patient volume Key challenges Beta site, no installations to visit Unknown company with unknown resources Hospital IS chief afraid of being stuck with a legacy system, and no support

Amelior ED® Clinical features Technology Patient tracking Nurse charting Physician charting CPOE Prescription writing Discharge instructions Reports engine Forms engine Onsite user training Technology Microsoft®-centric Bedside workstations Additional nursing and physician workstations ADT, Lab, X-ray interfaces 365 x 24 x 7 technical support Quarterly software upgrades Hardware refreshes

Implementation “big bang” vs phased approach Initial big bang in Nov 2001 Lack of complete lab and x-ray interface capability Speed and process issues resulted in a mutual agreement to take the system down Proof-of-concept in Fast track Completed interface work System turned on for rest of ED

Current Status Continuous operation since July 2001 90,000+ visits 100% use by physicians and nurses Bi-directional Interfaces: Lab orders and results X-ray orders and interpretations ADT information transfer Lifetime clinical record

Impact Decreased LOS by almost 1 hr in 1st 6 months Volume has increased 14% this year Eliminated handwriting issues No more pharmacy call backs Reduction in medication errors Reduction in “missed” orders Automated time stamp improved process analysis, accountability, and order execution times

Impact Greatly enhanced ability to determine prior visit actions, results and treatments Reduced “door to decision” time Streamlined orders process Unit clerks eliminated from process Improved protocol compliance

Impact Nearly paperless ED Improved transfer documentation No “paper chase” for lab or X-ray results No fighting over who gets the chart No lost or misplaced charts Improved transfer documentation Instant chart for the transfer now available Prompting for transfer (COBRA) documentation

Impact Financial Reduced walk-outs by 57% (> $1 million annually) 90% reduction in lines of transcription ($300k annual savings) Improved physician documentation Increased RVUs Length of laceration Critical care time well documented Reduction in calls for medical records Automated ICD-9, CPT and APC codes Charge capture

Impact Increased physician productivity = increased income

Impact Concerns New technology introduces complexities New users Data entry Safety feature bypass

Impact Concerns Different looking chart Medical staff outcry over change Small but vocal minority Education on benefits Modifications in font size appeased most Paper chart made available for consultants Additional layers of regulation Passwords HIPAA rules specific to EMRs

Summary A full feature EDIS can Reduce errors and improve patient safety Eliminate handwriting issues Improve workflow by reducing turn around times for lab, x-ray and nursing orders Improve data analysis and collection Enhance hospital and physician revenues Reduce length of stay

Summary Plan for an evolution and not a revolution Needs assessment drives the process Collaborative process Physician champions key to success Vendor environment is competitive and evolving Biggest may not be the best solution for your ED

Future of EDIS Bioterrorism monitoring and alerts Proactive CQI Enhanced automation Embedded digital imaging Artificial intelligence Mobile connectivity

“We have met future and it is us”

Resources Dr. Clifton Sheets sheets@bigplanet.com Mary Washington Hospital www.medicorp.org Patient Care Technology Systems www.pcts.com EDIS Symposium www.paacep.org AAEM www.aaem.org ACEP Emergency Medical Informatics Subsection www.acep.org