Improving Quality: How a Hospital Reduced Medication Errors

Pursuing Perfection: Raising the Bar for Health Care Performance

    • September 24, 2008

The problem: Medication safety was a concern at McLeod Regional Medical Center in Florence, S.C. A patient chart review found 3.5 harmful medication errors for each 1,000 doses administered in the 474-bed hospital.

While at the low end of the national average, that rate translated into 35 errors a day—mistakes serious enough to cause some degree of actual harm.

The proposed solution: Leadership of the nonprofit hospital and its parent corporation, McLeod Health, embraced a plan to automate the medication delivery process, adding safeguards against both prescribing and delivery mistakes.

The Robert Wood Johnson Foundation (RWJF) supported this work, and other quality improvements, through Pursuing Perfection: Raising the Bar for Health Care Performance.

The initiative was part of a comprehensive quality-improvement effort led by physicians and overseen by McLeod’s Clinical Effectiveness Department headed by Donna Isgett, RN, MSN, vice president for quality and safety. For Isgett and her colleagues, the objective was—and is—to anticipate medical errors in all areas and install systems to prevent them.

“No one comes to work saying, ‘I’m going to hurt some patients,’” says Marie Segars, RN, MSN, the hospital administrator. The McLeod strategy, she says, is to make it easy “to do the right thing and impossible to do the wrong thing.”

The project: A multidisciplinary team analyzed McLeod’s medication system—from the physician’s order of a medicine to its administration to the patient—and instituted numerous technology and process changes. The result was a streamlined dispensing system that reduced the number of steps—and the opportunity for error—from 17 to five.

One key ingredient was installation of automated medication storage and dispensing cabinets in all inpatient units. The hospital also instituted an electronic medical record system that includes bar coding to verify the patient receives the correct medicine. Like a grocery store clerk at the checkout counter, the nurse scans the medicine packaging and the patient’s wrist ban to ensure they match.

The addition of order-entry computers allows physicians to key in prescriptions instead of writing them. Along with eliminating illegible handwriting, the system warns of potential dangers, such as a hazardous interaction with the patient’s other medicines. The challenge is getting doctors to use this safer but—for some—slower alternative, says pharmacy director Natasha Nicol, PharmD.

Also important was elimination of what Nicol says was a punitive approach to medication errors. Who did it? That used to be the response, she explains. Now when there is a mistake, the system failed, not a person, she says. Instead of an error report, the worker fills out an Improve the Process form.

With the “no-blame culture” came a sharp increase in the number of staff-reported medication errors—from 70 a year to 200 a month. “That doesn’t mean more errors are happening. It means people are more comfortable telling you about them,” Nicol says.

Results: At the conclusion of RWJF funding in 2006, McLeod personnel reported:

  • The rate of harmful medication errors had dropped 90 percent: from 3.5 to 0.34 per 1,000 doses. As of September 2007, it was down still further—to 0.09 per 1,000 doses (97.4%), according to Nicol.
  • The improvements—especially the automated storage/dispensing devices—helped cut the average time to get an ordered medication to the patient from 90 to 15 minutes (an 83% reduction).

McLeod’s other Pursuing Perfection initiatives also had measurable impacts. Improvements in cardiac care helped reduce the heart attack mortality rate from 22 percent to 2 percent over two years (2002–2003), the hospital reported. Key to achieving this result was a concerted, collaborative effort by the emergency and cardiology staffs to expedite heart attack treatment—cutting the so-called “door-to-balloon time,” the time lapse from ER arrival to the process that opens up the victim’s blocked artery.

Additionally, the hospital instituted a new palliative care program aimed at reducing futile and unwanted hospital procedures.

At McLeod, says Isgett, quality is not a project but an integral, never-ending process. The hospital has received widespread recognition for its quality initiatives, most recently a citation of merit in the 2007 Quest for Quality Prize competition sponsored by the American Hospital Association, McKesson Corp. and McKesson Foundation.

RWJF perspective: Pursuing Perfection was a national program to improve patient outcomes by funding providers to redesign major care processes.

RWJF Senior Program Officer Rosemary Gibson, MSc, says the results achieved by Pursuing Perfection grantees sends a powerful message to the field: “Health care organizations can reach new thresholds of quality and safety. It is possible to make great strides in health care. This is what happens when we develop the knowledge, skills and will to do it.”

Project Duration: September 2001–March 2006

Award: $2,250,000 (three grants)

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