Technology and Error in the U.S.A.

1. Technology and Error in the U.S.A. David W. Bates, Medical Director of Clinical and Quality Analysis, Partners Healthcare Chief, Division of General Medicine, Brigham and Women’s Hospital

2. Overview • Nature/scope • Costs • Impact/potential of IS • CPOE • Bar-coding • Smart pumps • Current activities • Center of Excellence in Patient Safety • Signature Initiatives at Partners Healthcare • Conclusions

3. The Chasm Report “Indeed, between the health care that we now have, and the health care we could have, lies not just a gap, but a chasm.” Crossing the Quality Chasm: A New Health System for the 21st Century

4. Medication Error Frequency and Potential for Harm In 10,070 Orders 530 Medication Errors 1.4 per admission 35 Potential ADEs 5 Preventable ADEs • 1 in 100 medication errors results in an ADE • 7 in 100 represent potential ADEs

5. ADE Prevention Study: Key Results • 6.5 ADEs/100 admissions • 28% preventable • 3 potential ADEs for every preventable ADE • 62% of errors at ordering and transcription stages JAMA 1995;274:29-43

6. Incidence and Severity of Adverse Events after Discharge • 400 medical inpatients • Adverse event rate 19% • 6% preventable • 48% of ADEs resulting in at least non-permanent disability preventable • 6% ameliorable • Of adverse events • 66% were ADEs • 17% procedure-related Forster et al, Ann Intern Med, 2003

7. Sample Preventable Adverse Event • Patient with CHF started on spironolactone • Already on ACE, lasix, K • No electrolyte monitoring • Extreme weakness and anorexia developed at 2 weeks • K was over 7.5

8. ADE Outpatient Results • Study of over 2000 outpatients • 18% report problems with their medications • 35%--medication was not changed • 20%--symptoms lasting longer than 3 months • 3% had ADEs on chart review (n=66) • 5% required hospitalization • 13% were preventable • Discrepancy between patient reported and chart documented events Gandhi et al. JGIM 2000

9. ADE Outpatient Results • Impact on patients and system • Lower patient satisfaction • 48%--sought medical attention • 49%--experienced worry or discomfort • Correlates of patient-reported drug complications • Number of medical problems • Failure to explain side effects • Primary language other than English or Spanish

10. Admissions Due to ADEs • Few recent data • Wide range: 0.5-21% of all admissions • One recent study at BWH found 1.4% of admissions were due to ADEs • Originate in outpatient setting • 78% severe • 28% preventable Jha, et al. Ann Pharmacother, 2001

11. Ways IT Can Improve Safety • Prevent errors and adverse events • Facilitating a more rapid response after an adverse event has occurred • Tracking and providing feedback about adverse events

12. Main Strategies for Preventing Errors and AEs Using IT • Tools to improve communication • Making knowledge more readily accessible • Requiring key pieces of information • Assisting with calculations • Performing checks in real time • Assisting with monitoring • Providing decision support Bates and Gawande, NEJM 2003

13. Computerized Physician Order Entry • Single most powerful intervention for improving medication safety to date • Over 80% reduction in medication error rate • Need to have associated decision support if want to see high level of benefit

14. Improving the Quality of Drug Ordering with Order Entry • Streamline, structure process • Doses from menus • Decreased transcription • Complete orders required • Give information at the time needed • Show relevant laboratories • Guidelines • Guided dose algorithms • Perform checks in background Drug-allergy Dose ceiling Drug-lab Drug-drug Drug-patient

15. Interventional Trial Data • Design--controlled trial, using both contemporaneous and time series comparisons, over 15-month period • CPOE • All orders complete • Transcription minimized • Early checking including drug-allergy, drug-drug • 55% decrease in serious medication error rate JAMA 1998;280:1311-6

16. NEPHROS study Effect of real-time decision support for patients with renal insufficiency • Of 17,828 patients, 42% had some degree of renal insufficiency Control Interv Dose 54% 67% Frequency 35% 59% • LOS 0.5 days shorter Chertow et al, JAMA 2001

17. Allergy Alerts • 7,761 drug-allergy alerts in BWH inpatients, Aug-Oct 2002 • Alerts were overridden 80% of the time • Only 6% of alerts were triggered by an exact match between drug ordered and drug in allergy list

19. Key Areas of Decision Support • Requiring complete orders • Default doses • Drug-allergy checking • Renal dosing • Geriatric dosing • DDI checking • Drug-lab checking • Dose ceilings

20. Future Directions Regarding Alerts • Need to determine better when to alert • Perhaps more important, how to alert so that providers recognize important warnings • Cognitive issues, workflow • How to get people to document better • Make it easy to do right thing • What kind of information will prove most useful • Usability • Background processing, understanding context • How to deliver more complex decision support

21. Bar-coding • Technology is inexpensive • Would help in: • Matching medication orders and drug products • Medications dispensed/administered • Identifying correct patient • Will know • What/how much/who/when • Few published data so far, but experience in other industries suggest important benefit

22. Intravenous Drug Safety • Intravenous delivery a vulnerable spot • Hard to detect--true rate higher than realized • Very high severity level • Hard to intercept without changing systems • Effective interfaces will be key because integration critical • Expertise in “engineering out” errors pivotal • Need to build approaches that help clinicians do what they intend, don’t rely on training

24. Impact of “Smart” IV Pumps • Few administration errors get caught • Yet intravenous errors can be especially dangerous Case • Heparin bolus dose of 4000 units, followed by an infusion of 890 units/hr • 4000 unit bolus dose was given appropriately • But nurse misinterpreted the order and programmed the infusion device to deliver 4000 U/hour, not 890 U/hour • Smart pump alerted nurse • Early data—2 such errors/day in 400-bed hospital ISMP Newsletter Feb 6, 2002

25. Early Qualitative Findings • Critical drug infusion is complex • Handoffs from one area to another frequent and tricky • OR to recovery to ICU • Physicians and pharmacists often don’t understand the issues involved • Initial programming is not most of the programming

26. Pump Logs and Data in Them • Represent a treasure trove • Will be possible to ascertain how often warnings are going off • Whether specific individuals are especially likely to override • Whether some limits should be removed • Low end warnings may not be useful for some drugs

27. Other Non-IT Inpatient Approaches • IT not only way to improve safety by any means • 66% reduction in preventable ordering ADEs with pharmacist participation in ICU rounds Leape, JAMA, 2000 • Building a culture of safety is extremely important

28. Patient Computing at Partners • Patient Gateway • Secure portal for patients with their primary care practice • Practice Gateway • Secure portal for practice staff • Public Gateway • Portal to enroll and to access Patient Gateway • Evaluation • Funded by Markle Foundation • New AHRQ-funded study

30. Center of Excellence for Patient Safety Research & Practice David W. Bates, M.D. David Blumenthal, M.D. Eric Campbell, Ph.D. E. Francis Cook, Sc.D. Allan Frankel, M.D. Jerry Gurwitz, M.D. Rainu Kaushal, M.D. Carol Keohane, R.N. Barry Kitch, M.D. Lucian Leape, M.D. Jeffrey Rothschild, M.D.

31. Improve Medication Safety Across Clinical Settings • Extend research to various populations in various clinical settings • Eliminate gaps in current ME reduction research • Develop prevention and safety strategies • Develop and translate findings to an array of settings

32. Reporting and Surveillance Tool Safe Intravenous Infusion Systems Ambulatory Pediatric Epidemiology Study Inpatient Psychiatric Epidemiology Study Organizational culture in promoting patient safety Improving Safety in Nursing Homes

33. Project Synergy Reporting Study a variety of clinical settings METHODOLOGY DISSEMINATION Pediatric Eliminate gaps in ME research Improve Medication Safety Across Clinical Settings Psychiatric Develop strategies to improve patient safety IV System Nursing home Translate new strategies to an array of settings Culture

34. Concept • Medication safety is the area for which interventions are best-defined • Improve medication safety across Partners by: • Standardizing medication decision support • Prioritizing implementation of key interventions to improve administration and dispensing such as bar-coding and smart pumps • Monitoring routinely for ADEs and implementing simple and accessible computerized reporting • Standardizing information exchanged in clinical transitions including medication information Signature Initiatives

35. Inpatient Medication System of the Future • Providers write orders on computerized systems, get feedback • Orders sent directly to pharmacy (review) • Simple orders filled using automation • Point-of-care delivery devices linked with order-entry systems dispense medications • All drugs, patients, personnel bar-coded • Computerized MAR records what given, when • Administration via “smart” devices • Systems collect data about warnings

36. Outpatient Medication System of the Future • Providers write computerized orders • Screened at time written • Orders go electronically to pharmacy • Pharmacist review, counseling for new drugs • Simple orders filled using automation • ATM-like devices with simple fills • Patient web sites with medication information • Can track progress, report problems • Option to use home dispensing devices that record when medications taking

37. Reducing Error in Medicine “I don’t want to make the wrong mistake.” Yogi Berra