of the general public. This comes at the same time that the medical community is pressing for caps on malpractice settlements.

Transcription

1 OSHA Watch May/June 2003 Volume 5, No. 3 Patient Safety The gene pool could use a little chlorine. At least that s how it seems every time I open the newspaper or turn on the TV. We re inundated by headlines about an astounding array of medical bloopers. From the appalling stories of patients who get the wrong kidney removed, to patients being permanently maimed when a surgical drape catches fire during a procedure, to surgical instruments (including a 16-cm clamp) being accidentally left inside a patient s body after a procedure the unbelievable-but-true stories continue to make news. It s no wonder that last year the Institute of Medicine ranked hospitalization as the eighth leading cause of death in the U.S. How could anyone make such mistakes? Such stories plant seeds of mistrust about the healthcare industry in the collective minds Medical Mistakes Make Headlines of the general public. This comes at the same time that the medical community is pressing for caps on malpractice settlements. None of these incidents are believed to be malicious, but the troubling reality is that these are not just isolated events. Unfortunately, medical blunders including those in ambulatory settings occur more often than even the media reports. But your practice can stay off the evening news if you implement systems and processes that will minimize errors. Quality America s approach to safety in general is to provide practical ways to prevent accidents such as the ones reported in this special edition of OSHA Watch. Even though patient safety is not an OSHA concern (OSHA s regulations are designed to keep employees safe), we hope that our readers who value worker safety will also find a few strategies from this newsletter that will prevent a potential medical blooper. We understand that right now you re busy managing your bottom line, deciphering the changed CLIA Quality America: We Make Compliance Easy! regulation and meeting the HIPAA compliance deadline. But the tips provided in this OSHA Watch are quick to implement and have the added bonus of being FREE! Don t wait to make the medical blooper headlines! Put into practice the prevention techniques that make sense for your office, and do it today. Your practice can t afford to ignore this issue. Dr. Sheila Dunn, Editor Patient Safety Inside... The Alarming Statistics... 6 How To Respond To Medical Errors...10 Working Safely With Medications...12 Drug Barcoding...14 Plus... Special centerfold: How To Be More Involved In Your Healthcare Make copies to post in your practice or to hand out to your patients a special bonus item from Quality America, Inc.!

2 Page 2 To Err Is Human, But It s Still Shocking Three years ago, the National Academy of Science s Institute of Medicine (IOM) released a report that stunned the nation. To Err Is Human: Building a Safer Health System reported that between 44,000 and 98,000 people die in U.S. hospitals each year as a result of medical errors. The study noted that data pertained to hospitals only, and suggested that medical errors are likely to be just as prevalent throughout the entire healthcare system notably in ambulatory settings and retail pharmacies. Medical errors are the eighth leading cause of death and injury in the nation higher than motor vehicle accidents, breast cancer or AIDS. Each year an estimated 7,000 people die from medication errors alone about 16% more deaths than the number attributed to workrelated injuries. D E A T H S Patient Safety Leading Causes of Death in U.S. 16,516 AIDS 42,297 Breast Cancer 43,458 Motor Vehicle Accidents Medical Errors Source: IOM Study 1999, data from ,000-98,000 Errors occur not only in hospitals, but in other healthcare settings as well, such as physician offices and urgent care centers; however, the handful of data for outpatient settings has focused on anesthesia administration and lipoplasty. Three States Lead in Outpatient Medical Errors One study looked at outpatient surgery centers in Florida, New York and New Jersey, and reported that medical errors in these settings were higher than in hospital-based surgery suites. The authors found that facility accreditation and proactive development of policies, rather than reactive responses to adverse events, were the best means to ensure patient safety. Project HOPE: Health, 2002 What Patients Are Saying The IOM report generated lots of attention. According to a survey conducted by Kaiser Family Foundation, more than half of Americans followed it closely, and some reported a very real fear of medical errors: 42% of respondents had been affected by a medical error, either personally or through a friend or relative. 32% indicated that the error had a permanent negative effect on the patient s health. Overall, respondents to this survey thought the healthcare system was moderately safe. Another nationwide survey, conducted by the American Society of Health-System Pharmacists, found that: OSHA Watch March/April % of Americans were very concerned about being given the wrong medicine. 58% were very concerned about being given two or more medicines that interact in a negative way. 56% were very concerned about complications from a medical procedure. When asked in a survey about possible solutions to medical errors: 75% thought it would be most effective to keep health professionals with bad track records from providing care. 69% thought the problem could be solved through better training of health professionals. According to a national poll conducted by the National Patient Safety Foundation, most people believe that medical errors are due to the failure of individual providers. But this isn t necessarily so. The IOM report emphasized that most medical errors are systems related and not attributable to individual negligence or continued on next page

3 OSHA Watch March/April 2003 Page 3 Included in This Issue: How To Be More Involved In Your Healthcare misconduct. So, it follows that system improvements can reduce error rates and improve the quality of healthcare. Costs QA Poster Designed to Reduce Medical Errors A recent study supported by the Agency for Healthcare Research and Quality (AHRQ) found that doctors often do not do enough to help their patients make informed decisions. Uninvolved and uninformed patients are less likely to accept the doctor s choice of treatment and less likely to do what they need to do to make the treatment work. That s why Quality America has created a poster to help you involve your patients with their healthcare. The poster How To Be More Involved In Your Healthcare is included in this issue of OSHA Watch (see centerfold), and may be copied as a handout for your patients or to post in your practice. We join with the AHRQ and organizations like the Joint Commission on Accreditation of Healthcare Organizations in our belief that patients can play a vital role in making their healthcare safer by becoming active, involved and informed. from previous page Medical errors carry a high financial cost according to the IOM report, an estimated $37.6 billion each year. About $17 billion of those costs are associated with preventable errors. What Are Medical Errors? Medical errors occur when part of a medical care plan doesn t work out, or when the wrong plan was used in the first place. They can happen during even the most routine tasks. While most people believe that medical errors usually involve medications (wrong prescription or dosage) or mishandled surgeries (amputation of the wrong limb), there are many other types of medical errors, including: Diagnostic errors, such as: misdiagnoses that lead to an incorrect choice of therapy; incidents in which there is a failure to use an indicated diagnostic test or failure to act on abnormal results; misinterpretations of test results. Equipment failure, such as: defibrillators with dead batteries; intravenous pumps whose valves are easily dislodged or bumped, causing increased doses of medication over too short a period. Infections, such as: nosocomial infections; post-surgical wound infections. Blood transfusion-related injuries, such as: giving a patient the blood of the incorrect type. Misinterpretations of other medical orders, such as: failing to give a patient a salt-free meal, as ordered by a physician. Inexperience with technically difficult diagnostic procedures that can affect the accuracy of the results. A significant percentage of medical errors are medication-related. These are preventable mistakes in prescribing and delivering medication to patients, such as prescribing two or more drugs whose interaction is known to produce side effects, or prescribing a drug to which the patient is known to be allergic. continued on page 4 Unbelievable-but-True Medical Bloopers All of the following cases are true. Some sound so ridiculously unbelievable that you might be tempted to laugh out loud until you consider that people actually lost their lives or were permanently disabled in these situations. And all of these errors were preventable! New York: Neurosurgeon Operates on Wrong Side of Brain Partly because of a mix-up in x-rays, the chief neurosurgeon at Memorial Sloan-Kettering Cancer Center in Manhattan operated on the wrong side of a patient s brain. This happened in spite of the fact that Sloan-Kettering advertises that it delivers the best cancer care anywhere. (Look for more Medical Bloopers throughout this issue of OSHA Watch.)

4 Page 4 OSHA Watch March/April 2003 Patient Safety An adverse event is an injury caused by medical care that resulted in measurable disability or death. To Err Is Human from page 3 According to the IOM report, these errors account for one of 131 outpatient and one of 854 inpatient deaths. They include prescription and pharmacy-dispensing errors, as well as unintentional noncompliance with medication instructions. (For more about this subject, see Working Safely with...medications on page 12 of this issue.) What You Can Do to Minimize Medical Errors The Joint Commission on Accreditation of Healthcare Organizations has set a number of patient safety goals (see OSHA Watch, September/October 2002). The following ideas compiled from several of the studies mentioned in this article address some of these goals. Improve accuracy of patient identification. Before administering medications or collecting lab specimens, correctly identify patients. When collecting a blood specimen, ask the patient to state his/her name. Don t state the patient s name and ask the patient for affirmation. Should the patient s hearing be compromised or the level of alertness be altered by medication or illness, he/she may affirm a name that was not comprehended simply to be accommodating. Use at least one other patient identifier, such as the patient s address, telephone number, or date of birth, and compare the information with that on the request form. The patient s room number is NOT a proper identifier. Conduct a final verification process such as a time out prior to the start of any surgical or invasive procedure, to confirm the correct patient, procedure and site. Use active not passive communication techniques. Improve communication among caregivers. Set up a system to quickly communicate diagnostic test results when a patient needs critical care. The traditional call back system prolongs the time between test results and appropriate treatment. An automatic alerting system for communicating critical laboratory results can reduce that time. Likewise, a computerized reminder system to alert physicians to the proper timing of repeat tests reduces the number of patients who are subjected to unnecessary repeat testing. Develop a procedure to write down the order, perform the verifying read-back, and receive confirmation from the ordering individual. Use a standardized, written set of abbreviations, acronyms, and symbols throughout the organization, and identify those abbreviations that will not be used. Consider banning the use of abbreviations that have more than one meaning, such as PT, which could mean physical therapy, protime, or part-time (see chart on page 5). Eliminate wrong-site, wrongpatient and wrong-procedure surgery. Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available. Implement a process to mark the surgical site. Involve the patient in the marking process. continued on next page

5 OSHA Watch March/April 2003 Page 5 Abbreviation = Meaning Consequences Solutions 1. Bad Handwriting or Typo U = Units U mistaken as a zero or a number 4, resulting in Spell out IU = International unit overdose; IU can be read as IV SC or SQ = Subcutaneous Mistaken as SL (sublingual) Spell out SS = Sliding scale SS can be mistaken as 55 Spell out 2. Signs and Symbols & = And Ampersand (&) mistaken for a number, Use and especially if it is close to other marks / = Slash Mark (separates two Can be read as a number 1 Use per instead of a slash mark doses or indicates per < = Less than Sometimes mistakenly used opposite to what Spell out words > = More than was intended; with handwriting can be run into another notation and look like something else Trailing zero (2.0 instead of 2) Decimal often not seen in handwriting, leading Always use zero before a decimal or leading decimal (.2 instead to 10-fold dosing error when dose is ess than a whole unit of 0.2) and never use a trailing zero. 3. Greek Letters µg = micrograms Mistaken for mg (milligrams), resulting in overdose Spell out micrograms 4. Latin Terms and Abbreviations Q.D. = Every day A period after the Q has sometimes been mistaken for Use daily or every day an I, and the drug has been given QID (4 times daily) rather than daily. QOD = Every other day Misinterpreted as QD (daily) or QID (4 times daily); if Use every other day the O is poorly written, it looks like a period or an I. AU, AS, AD = Both ears, left ear, right ear Problem Prone Abbreviations Misinterpreted as the Latin abbreviation OU (both eyes), Spell out OS (left eye), or OD (right eye) PO/Per os = by mouth, orally Not understood or read incorrectly Spell out 5. Ambiguity (more than one meaning) D/C = Discharge; also discontinue Patients medications have been prematurely Spell out whether discharge or discontinued when D/C (for discharge ) was or discontinue misinterpreted as discontinue because followed by a list of drugs. HS = Half strength Misinterpreted as Latin abbreviation HS (hour of sleep) Spell out DPT = Demerol Phenergan- Misinterpreted as diptheria-pertussis-tetanus vaccine Always use the complete spelling Thorazine for drug names. Source: JCAHO Patient Safety Goals from previous page Improve the safety of infusion pumps. Ensure free-flow protection on all general-use and patientcontrolled anesthesia intravenous infusion pumps. Improve the effectiveness of clinical alarm systems. Implement regular preventive maintenance and testing of alarm systems. Assure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise. Big Brother Is Watching and so Is John Q. Public We have concluded that human error occurred at several points in the organ placement process that had no structured redundancy. Those were the words of Dr. William J. Fulkerson, vice president and CEO of Duke University Hospital, referring to the botched transplant operation earlier this year at one of the most respected medical facilities in the country. Even before that tragic incident, the federal government, managed health plans, JCAHO and other healthcare accrediting agencies were increasing scrutiny of efforts to reduce medical errors as were the media and the American public. Sure, we re all human. But human error is no excuse when there are simple ways to minimize the possibility of medical errors. Make sure you hold your mistakes to something that doesn t involve the life of another human being.

6 Page 6 OSHA Watch March/April 2003 Patient Safety Medical Errors: The Alarming Statistics From the National Academy of Sciences: A January 2003 report blames hospitals for tens of thousands of patient deaths each year from preventable causes. While focusing on hospital acquired infections due to unsanitary conditions or practices and inadequate medical care following diagnosed heart attacks, the report outlines 20 areas for reform, including improved treatment for diabetics, increased cancer screening, and better immunization for children and adults. From the Institute of Medicine: IOM reports that 98,000 Americans die each year and one million more suffer injuries from preventable medical errors. But the actual number of deaths is higher because the IOM only looked at errors committed in hospitals, and not in other settings such as clinics, outpatient surgery centers, and physician s offices. From the Federal Government: At press time, the House was considering a bill to cap damages in health lawsuits. The bill would set a $250,000 cap on non-economic damages, restrict punitive damages, limit attorney fees, and limit the timeframe in which suits can be filed. From the Annals of Internal Medicine: A new study reported in the Feb. 4, 2003 edition concludes that lifethreatening infections and other medical errors may occur more frequently with a patient s transition from hospital to home rather than from mistakes made in a hospital. Nearly 20% of 400 patients discharged from a large teaching hospital were victims of an adverse event that occurred after discharge, and resulted from the care they received rather than an underlying disease or condition. Researchers concluded that two-thirds of these incidents, many of which were related to antibiotics and other drugs, could have been prevented or minimized by better communication among doctors or between doctors and patients. Communication problems are worsening as care becomes technically more complicated and the healthcare system becomes increasingly fragmented. From the New England Journal of Medicine: Operating room teams around the country leave sponges, clamps and other tools inside about 1,500 patients every year, according to a report in the Jan NEJM. These errors increase during emergencies, with unplanned changes and/or North Carolina: Girl Dies After Transplant Error A 17-year-old girl died at Duke University Hospital after receiving a heart and lungs transplant from a donor with the wrong blood type. The organs she received came from a donor with type A blood; the patient s blood was O-positive. complications in the procedure, and with obese patients. Such mistakes are fortunately a small portion of the roughly 28 million operations a year in the U.S. In some cases, surgical teams failed to follow the standard practice of counting equipment before and after the operation; in other instances foreign objects were retained even when OR staff reported that they had performed instrument and sponge counts before and after surgery. Sponge counts were not performed after episiotomy closure or vaginal tear repairs and 11 of those procedures resulted in retained objects. continued on next page

7 OSHA Watch March/April 2003 Page 7 from previous page From the Journal of the American Medical Association: Nearly 2 million elderly outpatients experience medication errors annually. Of 30,000 elderly outpatients in New England, a study found 1,523 adverse drug events, including four deaths and 12 cases of permanent disability. Of these errors, more than a quarter were preventable. In addition to reviewing medication errors related to prescribing and dispensing, adverse reactions, and monitoring problems, the study was among the first to look at problems due to the patient s own actions. In 21.1% of the errors, the patients themselves were responsible, taking incorrect doses or taking medications for longer than they should have, refusing to take medication, or taking another person s medication. From the American Journal of Health-System Pharmacy: The adverse drug reaction database from a Florida teaching hospital identified 415 adverse events that occurred from 1994 to 2000, some of which resulted in disabling or life-threatening conditions or even death in patients. Other adverse reactions required prolonged hospitalization or a change in drug therapy or additional therapeutic intervention. Nearly 100 adverse drug events occurred in the ambulatory care setting and led to hospitalization. Ten major drug classes accounted for nearly 75% of all reports. The majority of problems were associated with anticoagulants, opiate agonists, insulins, benzodiazepines, hydantoins, and digoxin. Excessive anticoagulation or hemorrhagic events were key factors in one-third of all preventable adverse drug reactions, and another third was associated with central nervous system problems. Visit Quality America s OSHA Watch Resource Center for: Ask the Expert Updates on Smallpox and on West Nile Virus NEW! Question of the Month Archives Sharps Evaluation Forms & Instructions Sharps Injury Log Glutaraldehyde Policies & Procedures Eyewash Recommendations Gas Cylinder Safety Glass Capillary Tube Advisory Latex Allergy Advisory Hepatitis Test Information Links for Downloading MSDS & OSHA Regulations

8 Agency for Healthcare Research and Quality, Rockville, MD. How To Be More Involved In Your Healthcare Research shows that patients who are more involved with their medical care tend to get better results. That means taking part in decisions about your healthcare by communicating problems and asking questions of your doctor. Here are some ways you can do just that: MEDICATIONS Communicate with your doctor about what you are taking. Make sure that all of your doctors know about every medication you are taking, including prescription and over-the-counter medicines, and dietary supplements such as vitamins and herbs. At least once a year, bring all of your medicines and supplements with you to your doctor. Tell your doctor about allergies and adverse reactions to medications. Make sure your doctor knows about any allergies and adverse reactions you have had to medicines. This can help you avoid getting a medicine that can harm you. Make sure you can read your prescriptions. When your doctor writes you a prescription, make sure you can read it. If you can t read your doctor s handwriting, your pharmacist might not be able to either. Ask for information about your medicines in terms you can understand. HOSPITAL STAYS & SURGERY Choose your hospital if you can. If you have a choice, choose a hospital at which many patients have the procedure or surgery you need. Be clear on exactly what is to be done during surgery. If you are having surgery, make sure that you, your doctor, and your surgeon all agree and are clear on exactly what will be done. Doing surgery at the wrong site (for example, operating on the left knee instead of the right) is rare, but even once is too often. The good news is that wrong-site surgery is 100% preventable. Understand what to do when you are discharged. When you are being discharged from the hospital, ask your doctor to explain the treatment plan you will use at home. This includes learning about your medicines and finding out when you can get back to your regular activities. OTHER STEPS YOU CAN TAKE Speak up if you have questions or concerns. You have a right to question anyone who is involved with your care. Make sure that someone, such as your

9 Provided by Quality America, Inc., adapted from the Patient Fact Sheet, AHRQ Publication No. 00-PO38, February When your doctor prescribes medicines and when you receive them, ask questions like: What is the medicine for? How am I supposed to take it, and for how long? What side effects are likely? What do I do if they occur? Is this medicine safe to take with other medicines or dietary supplements I am taking? What food, drink, or activities should I avoid while taking this medicine? Make sure you get the right medicine and know how to take it. When you pick up your medicine from the pharmacy, ask: Is this the medicine that my doctor prescribed? If you have any questions about the directions on your medicine labels, ask. For example: Ask if four doses daily means taking a dose every 6 hours around the clock or just during regular waking hours. Ask about the best way to measure your liquid medicine; household teaspoons, for example, often do not hold a true teaspoon of liquid. Ask for written information about the side effects your medicine could cause. If you know what might happen, you will be better prepared if it does or, if something unexpected happens instead. That way, you can report the problem right away and get help before it gets worse personal doctor, is in charge of your care. This is especially important if you have many health problems or are in a hospital. Ask about handwashing. Whether you are in a doctor s office or a hospital, consider asking all healthcare workers who have direct contact with you whether they have washed their hands. Handwashing is an important way to prevent the spread of infections. Do not assume that everyone knows everything they need to. Make sure that all health professionals involved in your care have important health information about you. Ask a family member or friend to be there with you. Sometimes it helps to have someone with you to be your advocate. Especially when you are hospitalized, you may need someone who can help get things done and speak up for you if you can t. Know that more is not always better. It is a good idea to find out why a test or treatment is needed and how it can help you. You could be better off without it. Ask about test results. If you have a test, don t assume that no news is good news. Learn about your condition and treatments. Ask your doctor or nurse about your condition and treatments, and use other reliable sources to become better informed. For example, treatment recommendations based on the latest scientific evidence are available from the National Guidelines Clearinghouse at

10 Page 10 OSHA Watch March/April 2003 ASK THE EXPERT Medical Errors, Paperless MSDS, BBP and PPE Medical Errors and How to Respond Q: We can t believe the number of stupid mistakes we hear about in the news, where doctors, nurses and others make careless errors in their care of patients. It is embarrassing when our patients ask us about them! Some of us think errors are made because so much is expected of us, but others thing the mistakes are entirely preventable. What do you think? A: It is easy to blame the number of medical errors on our increasingly complex medical system, where multiple providers in different settings may manage one patient s care. Yet, healthcare professionals are human and, like everyone else, they make mistakes. Research clearly shows that the majority of medical errors can be prevented. One landmark study, in a review of 1,133 medical records on medical errors, indicated: 70% of adverse events were preventable 6% were potentially preventable 24% were not preventable Dr. Sheila Dunn President & CEO Quality America A study released last year, based on a chart review of 15,000 medical records in Colorado and Utah, found that 54% of surgical errors were preventable. My belief? True, we are human and mistakes will happen but clearly, the answer is to minimize the possibility of error. (And that s exactly why we produced for you this special edition of OSHA Watch.) Q: The people at Duke University Hospital were chastised for not telling the family of that transplant patient about the error they made in giving her organs with the wrong blood type. How would you recommend that situations like this be handled? A: Patients and physicians are miles apart on their views of what information should be disclosed after a medical error. Here s what the Journal of the American Medical Association said in a February 2003 report. Results of a focus group suggested that doctors should make more of an effort to apologize to their patients, in addition to providing them with information regarding the nature and cause of the error. Patients want to know what happened, why it happened, how to improve the outcome, and how to prevent recurrences. According to the report, physicians agreed that harmful errors should be disclosed but were guarded in what they told patients about errors. Although patients wanted an apology and other emotional support from physicians following errors, doctors were concerned Minnesota: Woman Receives Unneeded Double Mastectomy A laboratory mistake led to an unneeded double mastectomy for a 46-year-old woman. Her tissue from a biopsy for a benign spot was mixed up with the tissue from a woman with an aggressive form of cancer. The mistake was discovered two days after the surgery.. continued on next page

11 OSHA Watch March/April 2003 Page 11 from previous page that an apology might create legal liability. Physicians were also distraught over errors but did not know where to seek emotional support. JAMA researchers concluded that physicians should strive to meet patients desire for an apology and for information on the nature, cause and prevention of errors. Further, institutions could do a better job addressing the emotional needs of practitioners who are involved in medical errors. Oklahoma: Cancer Patients Get Hep C from Infected Needle A nurse anesthetist at a cancer clinic used a syringe to administer medicine to a patient who had hepatitis C, then drew more medicine from the same vial for the patient with the same syringe. Other patients were then given medicine from the same vial. At least 81 cancer patients were infected and 600 patients were exposed. On Another Subject: Tips for Paperless MSDS Q: We were approached by a company who will maintain our MSDS electronically rather than in paper format. Would an OSHA inspector cite us for this? A: OSHA permits paperless MSDS as long as they are accessible to employees. Be sure that: 1. Reliable computers are accessible at all times without an employee needing to ask for permission. 2. Employees are trained how to use the computer, including any specific software considerations. 3. You have an adequate backup as well as a written plan for rapid access to hazard information in the event of an emergency. The plan should include processes for access during power outages, equipment failure, online access delays, etc. 4. The electronic access system is part of your overall hazard communication program. 5. Your staff and any emergency responders must be able to immediately obtain hard copies of the MSDS s, if needed or desired. If your database is accessible to the required employees on your intranet, you should be okay. Most large medical practices that go the electronic route still keep a single master hard copy file. More Precautions for Preventing BBP Exposure Q: What precautions should workers take when removing the rubber stoppers from vacuum blood tubes? A: This procedure definitely produces aerosols, so workers need to wear gloves, face and body protection, OR perform the procedure behind a Plexiglas barrier, OR use a 2 x 2 gauze to remove the stoppers. All these methods will prevent employee exposure to aerosols that could transmit bloodborne pathogens such as hepatitis and HIV. PPE for Fingersticks? Q: We do fingerstick procedures in our office. Does this procedure constitute a splash or spill risk that requires gowns? A: No, collecting a fingerstick blood sample is NOT a procedure where splashing or spraying could be reasonably anticipated, so gowns and face protection are not necessary. Be sure to wear gloves, though, since this is a vascular access procedure. Ask The Expert! We invite you to leave a message when you visit Quality America s OSHA Watch Resource Center or write to: PHARMACY I I think it it says... take 22 capsules times a day... or...or something... Quality America, Inc. PO Box 8787 Asheville, NC

12 Page 12 OSHA Watch March/April 2003 Working Safely with... Medications About 7,000 patient deaths per year are attributed to drug errors, including wrong drugs, wrong doses or fatal combinations. A 2002 study of 368 hospitals blamed overworked nursing staff, doctors handwriting and computer-entry errors for drug mistakes. Pharmacists have reported many mix-ups in drugs with similar names, like the anti-convulsant Lamictal and the anti-fungal Lamisil, or the antihistamine Zyrtec and the ulcer drug Zantac. But patients have also been given wrong drugs because they have names like other patients, because a nurse has handed out drugs without realizing a previous nurse did so, or because doses got mixed up. Preventing potentially deadly mistakes when working with medications is easy when heeding a few simple tips: Medication Administration Write the purpose of the medication (that is, the diagnosis or the indication for use) on the prescription. This is an inexpensive and efficient way to minimize errors and can help the pharmacist screen the medication order for the proper dose, duration, and appropriateness. It might also enable the pharmacist to intervene when multiple prescribers unknowingly order Patient Safety duplicative therapy for the same patient. Writing the medication s purpose on the prescription can also minimize the risk of confusion resulting from lookalike names of medications, as well as the risk of misinterpretation resulting from poorly handwritten orders (also see below). Use information technology, such as hand-held computers, to eliminate reliance on handwriting for ordering medications and other treatment needs. Standardize treatment policies and protocols to avoid confusion and reliance on memory, which is known to be fallible and responsible for many errors. Develop and implement a policy for taking verbal or telephone orders. For example, when taking verbal drug orders, clearly repeat the name of the drug and the dosage ordered, request or provide correct spelling, and spell out the number. This is particularly important for sound-alike drugs. Avoid abbreviations. For example, 1 tab tid should be communicated as Take/give one tablet three times daily. (See the chart on page 5 of this newsletter for more suggestions related to the use of abbreviations, symbols, etc.) Standardize and limit the number of available drug concentrations of high-alert medications. Separate heparin and insulin; remove them from close proximity to each other on the tops of medication carts. continued on next page

13 OSHA Watch March/April 2003 Page 13 Patient Safety Reporting Adverse Events: Voluntary or Mandatory? Systems to promote voluntary reporting of adverse events would improve patient safety, yet healthcare workers fear sanctions and public disclosure, and fail to perceive any benefits of reporting. Despite these issues, interest in development of voluntary adverse event reporting systems has reached unprecedented levels. Development of mandatory systems for adverse event reporting are now in place in 20 states, but the type of adverse events that must be reported varies widely, as does the completeness or usability of the report issued. Only 10 states (Arizona, California, Connecticut, Florida, New Jersey, New York, Ohio, Pennsylvania, Rhode Island, Texas) have placed any regulations on office-based procedures. Only a handful of states (including California, Florida, New Jersey, New York, Rhode Island) have reporting systems for outpatient settings. New Jersey and Mississippi are the only states that mandate the reporting of adverse events that occur in physician offices. In any case, very few states have the requisite personnel to fully analyze reports, and as such, medical facilities receive little feedback. Four major national voluntary reporting systems are in operation: 1. The JCAHO s Sentinel Events Reporting Program addresses a wide range of serious events, and resulting recommendations are published. 2. The Institute for Safe Medication Practices and U.S. Pharmacopeia collect reports of adverse drug events (ADEs), analyze them, and disseminate recommendations accordingly. 3. The Food and Drug Administration-U.S. Pharmacopeia MedMARx program analyzes medication error reports provided by hospitals and delivers results of those analyses. 4. The Centers for Disease Control and Prevention s National Nosocomial Infection Survey uses sophisticated analysis to establish national benchmarks and reports institution-specific rates to participating hospitals. One small-scale voluntary program that shows promise is the Department of Veterans Affairs system-wide reporting program which features safe reporting (immunity from discipline), simplicity (a one-page report is used), expert analysis, and timely dissemination of recommendations. Editor s note: See more on legislation defining a new voluntary medical error reporting system on page 14 of this newsletter. Sources: The New England Journal of Medicine (Nov. 14, 2002), Journal for Healthcare Quality (Sept./Oct. 2002) Massachusetts: Man Sues Doctor Who Left Surgery to Cash Check An orthopedic surgeon acknowledged that he left a man on the operating table with an open incision in his back, midway through spinal surgery. The patient suffered permanent disability with severe pain in his legs after the physician abandoned him for 35 minutes in the operating room to cash a check at a nearby bank. from previous page Medication Storage Store all prescription drugs in a secured area. Controlling access to these items, as well as to samples and prescription pads, will minimize the risk of theft or unauthorized use. Keep DEA ordering forms and controlled substances in a secure and locked area. Limit access to these forms and drugs to specific staff selected by management. Maintain a record of the date, name, strength, and amount of controlled drugs ordered. Keep a dispensing record that includes date, patient name, drug name and strength of drug, amount dispensed, physician name, and name and signature of person who dispensed the drug. Take inventory at regular intervals and resolve discrepancies between the inventory record and the dispensing record.

14 Page 14 OSHA Watch March/April 2003 Patient Safety Act Passed The House of Representatives overwhelmingly passed the Patient Safety and Quality Improvement Act (HR 663), intended to help report and reduce medical errors. The bill defines a new voluntary medical error reporting system. It works like this: The Secretary of Health and Human Services (HHS) will certify a number of private and public organizations to act as Patient Safety Organizations (PSOs). These PSOs would analyze data on medical errors, determine the causes of errors, and compile and disseminate reports to providers to help them implement changes that will improve patient safety. Confidentiality protections would apply to those who report medical errors; civil fines could be made against healthcare providers that retaliate against workers who report medical errors to PSOs. Introduced by Rep. Michael Bilirakis (R-FL), HR 663 has been IN THE NEWS referred to the Senate Committee on Health, Education, Labor and Pensions. To read the Patient Safety and Quality Improvement Act, visit and search using HR 663. Zyrtec or Zantac? FDA Mandates Drug Bar Coding As a part of a series of government steps to help prevent deadly medical mistakes, the Food and Drug Administration will soon require every medication to carry a bar code label so that hospitals can use scanners to verify that patients get the right drug dose at the right time. The FDA estimates that as many as 7,000 hospitalized patients die annually because of drug errors, where a wrong drug or wrong dose is administered. FDA Commissioner Dr. Mark B. McClellan estimated that the bar code requirement, introduced as a proposal expected to gain final adoption after a 90-day period of public comment, would prevent 400,000 bad drug reactions from headaches to death over the next 20 years. Bar code systems verify that prescriptions entered by physicians into a computer are checked against parameters like the What s the difference between danger, caution and warning signs? When are these signs needed in the workplace? Find out in the next edition of OSHA Watch. Patient Safety patient s age, weight, diagnosis and other drugs taken. Then, at bedside, a nurse scans a bar code on the patient s bracelet and a bar code on the medication. The computer instantly reads whether the medication is the same drug that the doctor ordered, with the same dose, dispensing time and delivery method, and sounds an alarm if there is a mismatch. FDA estimates that it will cost pharmaceutical companies $50 million to put bar codes on every product and that hospitals will spend more than $7 billion on scanners and computers. Currently, only about 35% of all hospital medications are bar coded. The UPC bar codes used in supermarkets are too big for most medication packages, and drug companies have had difficulty settling on a standard. Finally, without the codes, hospitals have been reluctant to buy scanning equipment. But several companies have adopted a bar code only about 20 millimeters long (some four-fifths of an inch) by 3 millimeters high, which should fit the bill.

15 OSHA Watch March/April 2003 Page 15 HOT FINDS and Cool Websites Patient Safety Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact, a report to the President from the Quality Interagency Coordination (QUIC) Task Force (Feb. 2000), can be found at: A hard copy (Publication No. OM ) is available from the AHRQ Publications Clearinghouse, call: or ahrqpubs@ahrq.gov National Patient Safety Goals from the Joint Commission on Accreditation of Healthcare Organizations are available at: For information about medical errors, visit: To access the 287-page Institute of Medicine study on medical errors, To Err is Human: Building a Safer Health System, go to: Kentucky: Surgeon Brands Patient s Uterus with Initials of Alma Mater A Kentucky surgeon sued for branding a patient s uterus with the initials of his alma mater recently defended his actions. The surgeon cauterized a two-inch UK as a routine way to identify left from right. After viewing a tape of the operation, the patient sued, claiming emotional distress. Maryland: Woman Dies Participating in Johns Hopkins Study A woman volunteering for an asthma experiment conducted by Johns Hopkins University died after inhaling hexamethonium, a chemical which researchers had not gotten approval from the Food and Drug Administration to use in the study. Survey Says! Readership Survey Results A salute to all who completed our 2003 OSHA Watch readership survey! Results show that: 99% of respondents rate OSHA Watch to be excellent. 99% of respondents name Ask The Expert as their favorite feature in OSHA Watch. 96% of respondents rate the frequency of OSHA Watch to be about right. 92% of respondents said they prefer a hard copy of OSHA Watch, versus an ed version. We received several ideas from readers for new features in OSHA Watch and we re looking into how we can best implement them. Stay tuned!

16 Page 16 Uh, Speaking of Human Error This entire issue of OSHA Watch has been focused on preventing errors. Well, a problem in one of our recent newsletters wasn t a life or death mistake, but it was still embarrassing! A chart we published to illustrate harmful noise levels did not print correctly (yeah, we ll just blame it on the printers!), which pretty much rendered it useless. We apologize for the confusion and thank our loyal readers for pointing out this problem (it s always nice to know you re reading). Here s the chart again hopefully mistake-free! Shotgun blast Band concert Diesel truck Power lawnmower Child screaming Tea kettle whistling Alarm clock ringing Microwave oven Rain falling Refrigerator running 20 db Watch ticking 30 db 50 db 60 db 70 db db 85 db 90 db 100 db 60 Decibels Typical daytime ordinance noise limit 50 Decibels Typical nighttime ordinance noise limit 120 db ACME Trucking 90 Decibels OSHA identifies less than 90 db as safe noise level 85 Decibels Protection advised for prolonged exposure 75 Decibels EPA recommends protection for 8 hour exposure 140 db 115 Decibels OSHA forbids any unprotected exposure OSHA Watch March/April 2003 MOVED? Be sure to keep Quality America informed if your practice moves, or if you have an address change. Coming Next Issue Look for the May/June 2003 edition of OSHA Watch with all your favorite features, including... Ask The Expert In The News Plus A Special Report on Emergency Preparedness and much more! OSHA Watch Published Bimonthly by Dr. Sheila Dunn, President & CEO PO Box 8787 Asheville, NC ANSWER TO LAST MONTH S QUESTION OF THE MONTH What posters are required by Federal law in an ambulatory medical practice? ANSWER: The only poster required by OSHA is the It s The Law poster (Form 3165), which is included in Quality America s OSHA Safety Program manual. Other non-osha posters that your practice should post are the EEOC notice, the minimum wage law and the Polygraph Law posters. If your practice employs 50 or more employees, you also need to display the Family and Medical Leave Act poster. To determine exactly which posters are needed in a medical practice, visit the Department of Labor s poster advisor website at Subscription Rates: 1 Year - $79 2 Years - $145 3 Years - $ , Quality America, Inc. All rights reserved. No part of this publication may be reproduced, stored in any retrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise without the prior written permission of the publisher, Quality America, Inc.