Technology Slashes In-Hospital
Medication Risk

By Jill Cueni-Cohen
When a report from the National Institute of Health was released in 1999 stating that “more people die from medical mistakes each year than from highway accidents, breast cancer or AIDs,” administrators at Ohio Valley General Hospital decided to take action.

“The number of patients estimated to die each year from medical mistakes is equivalent to three jumbo jets crashing every two days,” said Greg Erhard, Director of Marketing and Physician Development at Ohio Valley. Referring to two reports from the Institute of Medicine and Harvard University, Erhard noted that nearly 100,000 people die each year because of medical errors.

Administrators of Ohio Valley General Hospital took those startling statistics seriously and immediately began searching for a solution to medication-related mistakes, which according to Peg Spisak, RN, Director of Quality and Risk Management, are the most common medical errors.

Mistakes involving incorrect medications or wrong dosages result from the critical shortage of nurse and pharmacy professionals. This labor gap has increased nurses’ workloads and shortened their response times. The additional challenge of having to keep updated on the latest advances in medications, devices, and therapies has also played a role in exacerbating this problem.

A Local Solution
To reduce medication-related risk at Ohio Valley, the hospital took the initiative to invest approximately $1 million into developing a system that combines the “supermarket-technology” of bar coding with wireless data transmission and applies it to medication, patients, and hospital personnel. In 2001, Ohio Valley went live with a bar code and wireless data transmission scanning system proven to dramatically reduce medication errors by 87 percent.

“There were errors going on that people didn’t even know they were making and many went unnoticed,” recalled Spisak, adding, “If nurses make a mistake now, they get error messages and realize it right away. It’s a big learning curve, but every time this system prevents them from making a medication error, they’re believers.”

Using a hand-held scanning device, a nurse scans his or her identification badge, the patient’s wristband, and the intravenous (IV) medication bag to establish the accurate identity of caregiver, patient, medication, and dosage level.

“Putting money into patient safety is never a mistake,” noted Spisak. She pointed out that the Food and Drug Administration (FDA) only last year began to require bar coding on most prescription drugs and some over-the-counter medications.

Pioneering Automatic Data Collection
Despite the FDA’s stipulation, the federal government has yet to mandate that all healthcare providers in the United States implement bar-coding systems. In December 2003, however, Ohio Valley surpassed even that technology when it was chosen to become the first hospital in the country to couple bar coding with an IV safety system.

“The administration of IV medications poses the greatest risk for harm to patients,” said Spisak. “IV errors could actually kill people.”

This groundbreaking method of protecting patients is part of a beta project implemented by McKesson Automation Inc., the Pittsburgh-based company that invented Admin-Rx™, and ALARIS Medical Systems, a San Diego firm that develops and sells products called “smart pumps” to regulate the safe delivery of IV medications.

According to Erhard, in 2002, the hospital was already interested in pursuing the use of infusion “smart pumps” when they were approached by ALARIS and McKesson about becoming the first beta site for an IV safety system.

Ohio Valley Advantage
Ohio Valley’s IV safety system provides nurses, physicians, and hospital pharmacists with real-time access to patient information from nearly anywhere in the hospital. The electronically operated infusion of IV medications by the “smart pump” will halt immediately if a bar code irregularity is detected.

“The melding of these two technologies helps us to make sure we’re adhering to the five rights: Right patient, right medication, right dose, right route, at the right time, said Spisak.

In a market dominated by university hospitals, we have taken a leadership role in medication safety,” noted Erhard, adding that the federal government is considering ways to help hospitals put this kind of technology in place, but the cost is prohibitive, especially for smaller hospitals.

“Hospitals have to look at their long-range plans. Then, as budget allows, put in bar coding and install the wireless network. This takes years of planning,” said Erhard.

“Last year, the Joint Commission on Accreditation of Health Care Organizations (JCAHO), considered making bar coding one of its patient safety goals, but they’ve held off on doing that because of the cost,” Erhard explained. “Building that infrastructure, upgrading our local network — it all costs money, because the equipment communicates wirelessly. We like to think of ourselves as pioneers, because this is going to be where patient safety is heading in the next 20 years.”

“The busier nurses get, the more we need to rely on this kind of technology,” said Spisak. “Patients deserve it.”