This article first appeared in the St. Louis Beacon, July 29, 2008 - Diane Ray calls it "drilling down."
It's what a hospital does when it wants to find out why a medical mistake happened. Officials dig through the data, trace the path of a patient through the hospital and the care given to find out what went wrong.
"You get to the root cause and you analyze where the breakdown occurred," says Ray, director of nursing at St. Luke's Hospital in west St. Louis County.
More often than not, it's a medication error. That's the most common type of mistake in medicine.
That's why St. Luke's and at least seven other area hospitals started using bar codes on medications in the past several years to cut down on those types of mistakes.
The idea is simple in theory: a nurse uses a scanner -- like those used in grocery stores -- to match the information on the bar code label of a drug to the bar code on the wristband of a patient. The nurse gets alerted when the two don't match.
Nurses found the bar code system difficult to get used to when St. Luke's started it about three years ago. "It was the scanners more than anything," Ray said. They didn't always scan the first or second time. "It did slow nurses down," she said.
But it's second nature to nurses now, said Kelly Stinson, a head nurse at St. Luke's. Nurses use the scanners with a laptop computer in each patient's room. If a nurse is about to give a dose or medication to a patient that doesn't match the barcode, the computer alerts the nurse with a typed message.
Stinson said the system allows nurses to print out medication labels at bedside on a laptop, a big improvement over old system that required leaving the room, going to a nurse's desk and getting a label.
"I do believe it has prevented medical errors," Ray said. About three weeks after the hospital started using bar coding, Ray said one of the hospital's best nurses, who had been most resistant to the change, pulled her aside and said quietly that the system had kept her from making a medication error.
"It really is a second chance for the nurse" to stop and think about what they're doing, Ray said, since one of the riskiest steps a nurse takes in a day is giving medication to a patient.
Many Systems and Steps to Safety
But bar codes are just one of many steps that St. Louis area hospitals are taking to prevent mistakes and improve patient safety. Other technologies include computerized physician order entry, IV "smart pumps" and computerized adverse drug event monitoring.
Slower to adopt these technologies than other parts of the country, St. Louis area hospitals are beginning to install systems that enhance communication between doctors, nurses, pharmacists and others to more accurately follow treatment guidelines, use diagnostic tests more appropriately and prevent medication errors.
Computerized physician order entry, or CPOE, bypasses the old method of writing down information on paper in favor of computerized records. About 27 percent of hospitals nationally use CPOE. Studies show it helps reduce three types of errors:
- Under-use of needed medications, such as providing aspirin to heart patients, particularly those who experienced heart attacks.
- Overuse of diagnostic tests, such as using more expensive and invasive contrast dyes in MRI tests when non-contrast dyes would serve the same purpose.
- Medication errors. Computers provide reminders regarding type and dosage of medication, as well as warn of possible allergic reactions and adverse drug interactions.
Dr. John Zalewski has been a local internist for 24 years. He's also the medical director for adult medicine for St. John's Mercy Medical Group, which has 170 doctors and 25 nurse practitioners. About half of the group has converted to electronic records, and Zalewski's office in Crestwood has been on electronic health records since February.
"We didn't do this as a system to save physicians' time," he says. "Right now it's definitely not saving physicians time." In fact, he estimates the new method has added an hour or more to his day, which is already filled with seeing patients. Eventually, he hopes the system will take the same time as paper records, and maybe move even a little faster.
Eliminating the Unreadable Prescription
The reason for the conversion is that with an electronic system doctors can share information so much easier and faster than with paper. For instance, if Zalewski has a patient with a complicated medical history, all that information can now be stored, shared and quickly retrieved on a computer.
"If my patient shows up in the ER at St. John's a year from now, the ER doc will be able to take a look and say, 'Here's the story on this patient,' " Zalewski said. "It's better medical care. It's better for patients."
Electronic records also reduce medication mistakes, by cutting out the old system of doctors scribbling unreadable prescription slips. "We now either print them out or electronically transmit directly to the pharmacy," Zalewski said.
Electronic records can also provide reminders of needed care, for example if a patient is over 65 and never had the pneumonia vaccine. The system also tracks tests that were ordered to see if they were done and whether the doctor got the results back.
"That kind of stuff is really exciting when you think of the potential to make care better," Zalewski said. "It's better care if you do it right. But it's only as good as what you put in there."
"Smart pumps" and computerized adverse drug monitoring, or CADM are aimed at preventing dosage errors and adverse interactions among medications. Smart pumps are routinely replacing older medication delivery systems in hospitals and CADM has been a feature of stand-alone pharmacy systems in hospitals for some time.
Smart pumps have built-in safeguards for use on either adults or children, in intensive care units or in the neonatal ICU. The pumps adjust for patient age, weight and have predetermined drug limits. While studies have documented significant reductions in errors, the pumps can be overridden, thus defeating one of the main reasons for their existence.
No Magic Bullets
While there is enormous potential in reducing errors and improving patient care, these systems have not proven universally successful. Experience at several major hospitals, including Northwestern Memorial in Chicago, show that there also needs to be hands-on involvement of health care providers, including doctors, nurses and pharmacists, to supplement the limited artificial intelligence embedded in these technologies.
"They are no magic bullets," said Denise Murphy, vice president of safety and quality at Barnes-Jewish Hospital.
Given the demands on their time, it's not always easy to get medical staffers involved in new systems.
"We have created a system where nurses have 150 tasks to perform in the next 60 minutes," Murphy said. "Doctors and nurses all buy in to the importance of patient safety, but they also have to understand what is in it for them as professionals."
One lesson to be learned from other hospitals' experience is that each hospital must analyze the types of errors that occur in their system and why they happen. Only then should technologies be designed and selected to address those specific issues.
Another issue for St. Louis is the type of system it has. Areas of the country that have integrated medical systems -- where doctors are often employees of hospitals and are tied more closely to those systems -- are more likely to adopt patient safety technology than other more loosely structured markets.
St. Louis has historically been a market of independent doctors and hospitals. Over the past decade, St. Louis has moved in the direction of hospital system consolidation and closer relationships between hospitals and physicians. As a result, all of the major health systems are in the process of implementing one or more of these technologies.
Peter Strauss is president of Health Planning Solutions, a firm that advises the health care industry on strategic and operational health-care issues. Joan Little is a St. Louis freelance writer.