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More Ways to Fight Medical Errors . . . and Yet We Still Need to Do More

April 12, 2011 – 5:33 pm

daphne_111610happyToday was a good day in the fight against medical errors. Yes, it should be a fight!

In our daily newsletter today we reported that the U.S. Department of Health and Human Services (HHS) is investing up to $1 billion in federal funding to launch the Partnership for Patients, a national program that HHS believes will “save 60,000 lives by stopping millions of preventable injuries and complications in patient care over the next three years.” (If that sort of spending right after a near-shutdown of the government worries you, here’s some more good news: HHS reports that the new program could reduce Medicare costs by about $50 billion over the next 10 years.)

The partnership will start by focusing on “medical errors and complications” such as adverse drug reactions, surgical site infections, and more.

Also today, VHA Inc. kicked off an initiative to cut errors in member hospitals. We reported that 12 hospitals in Indiana, Kentucky, Michigan and Ohio have joined “Target Zero,” an initiative sponsored by VHA’s Central region and Healthcare Performance Improvement LLC (HPI). To get an idea of the seriousness behind this initiative, check out this blog written by Craig Clapper, founding partner and the chief knowledge officer of HPI.

We also got word of improvements made by Arkansas Methodist Medical Center (AMMC) to reduce catheter-associated urinary tract infections. The hospital started using Medline Industries Inc.’s ERASE CAUTI system a year ago and has seen a 21% reduction in catheterizations and CAUTIs, Medline reported today. Offering a one-layer tray design for catheter kits along with training, the company is promoting its ERASE CAUTI program.

“The one-layer tray design is labeled in a specific sequence that helps guide our nurses during the catheterization process to adhere to current CDC recommendations, including aseptic technique,” said Lisa Bridges, RN, infection preventionist for AMMC, in a press release. “To help us reduce catheterizations, we are requiring our entire nursing staff to take the program education on the alternatives to catheterization. Plus, the new tray has a checklist to help the nurse make a decision on whether catheterization is appropriate for the patient and to assure the education transfers into everyday clinical practice.”

These programs, of course, are just the beginning. Judging from the March and April Safety Briefs in the Institute for Safe Medication Practices’s Medication Safety Alert! newsletters, medical errors continue to threaten patients. Drug shortages are prompting hospitals to stock replacement items they aren’t quite familiar with, for instance, so mistakes could be made in identification and preparation. ISMP has put together its ISMP Quarterly Action Agenda warning hospitals and clinics of possible problems and recommendations, which could help reduce risks.

As packaging professionals, you can help by making product names and dosages stand out on labels and from similar-looking products AND by providing bar codes or other automatic identification technologies to lessen the chance for human error. Offer ready-to-use items whenever possible to eliminate risks associated with repackaging or reformulating.

And if you can provide procedure kits that are packed and assembled to follow the steps typical for that procedure, you will eliminate the guesswork and struggle that can happen in high-stress environments like emergency departments or operating rooms. Nurses don’t like to dig around in sterile kits for gloves or prep pads, for instance. (I learned that and more at last year’s Healthcare Packaging Immersion Experience.)

Daphne Allen

  1. 2 Responses to “More Ways to Fight Medical Errors . . . and Yet We Still Need to Do More”

  2. I had one more thought. If VHA is interested in cutting errors down to zero in its member hospitals, it will be advising hospital to buy products that are designed to reduce errors. Manufacturers should then review their product lines to ensure they have done all they can in this regard. Products that have been involved in past errors could very well be discontinued.

    By dallen on Apr 13, 2011

  3. Using an automated pharmacy system is a way to cut down on medication errors. Hospitals can almost completely remove error from the distribution system by switching to this.

    By Talyst on May 18, 2011

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