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ELIMINATING HEALTHCARE ERRORS THROUGH MOBILE COMPUTING

Introduction

Medical errors cause a great deal of human tragedy ranging from lack of efficacy to permanent disability and even death. Error rates in medical institutions are hard to establish because we usually don’t hear about them. Only a fraction of the errors are published in professional journals, and there are no requirements in most states to share or analyze information on errors. "It’s something that we don’t want to talk about, and I’ve always been troubled by that," said the former president of the American Society of Hospital Pharmacists. "It’s just been sort of a sin committed by hospital administrators to avoid any potential suit." ^¹

The head of the Department of Pharmacy Care Systems at Auburn University, one of the country’s preeminent medication error experts, estimates that there is one error per patient per day in every hospital. ^² If the experience of New York, one of the few states that track the outcome of medication errors, holds true for the nation, more than 830 patients may be dying each year from medication mistakes in the United States. Details on medication errors are locked away in the federal National Practitioner Data Bank, part of the U.S. Department of Health and Human Services, which threatens a $10,000 fine for anyone who publicly disclosed its information.

Medications are one area where mistakes can occur in medical institutions. There are other areas, such as the laboratory and the blood bank, where mistakes occur. Most of us just see the tip of the iceberg because many settlement agreements contain a no publicity clause. In many cases plaintiffs are put in the awkward position of having to choose between a settlement and publicity. There is growing evidence, compiled by the medical profession itself, that serious hospital errors occur regularly. Allowed to pour over the medical records in New York state hospitals, the Harvard Medical Practice Study showed in 1991 that 4 percent of all hospitalized patients suffered injuries resulting from medical errors that either prolonged their hospital stay or resulted in disability. Fourteen percent of those injuries were fatal.^³

Mobile Handheld Computers

Mistakes commonly made by caregivers can be avoided by the use of mobile handheld computer technology. By placing a computer in the hands of caregivers at bedside, hospital administrators can gain assurance that procedures are being followed. If a caregiver has to use a handheld computer to generate labels for specimens, then the caregiver cannot ignore procedures. The procedure as programmed into the handheld computer must be followed to generate the specimen label. Hopefully, the laboratory won’t accept samples that are not properly labelled. As the medical industry moves to managed care and the creation of integrated health delivery systems, the errors committed by caregivers will become more obvious. Healthcare providers have formed alliances or acquired facilities in order to treat the 500,000 to 1.5 million patients under each of their healthcare organizations. More than 80 percent of the 5,500 acute-care facilities in the United States now are affiliated with some type of health network. It is estimated that by the year 2000 that number will swell to 100 percent, when the market is expected to be consolidated into just a few hundred large, affiliated, healthcare systems. These large healthcare providers are closely monitoring the performance of individual hospitals and error rates are being compared to other hospitals in the group. Mobile handheld computers are being deployed to reduce error rates and enforce procedures.

Implementation

The first step in implementing mobile handheld computers requires printing bar coded patient ID wristbands in admissions. Once patients are bar coded, positive ID for blood specimens, test orders, X-rays, billing and numerous other hospital procedures can be accomplished accurately and rapidly, with dramatically reduced potential for error by merely scanning the bar coded wristband. Hospitals that have implemented this system have found patient reaction extremely positive. Patients see that they are being cared for in an efficient, high-tech environment, and respond favorably to it.

Once admissions has implemented positive patient identification, other hospital departments can be addressed:

Laboratory. In 1990, approximately 5 billion laboratory tests were performed in the United States, with laboratory costs estimated to be 5%-7% of total health care dollars. Many delays in receiving laboratory test results, or not receiving them at all, can be directly attributed to incomplete forms. One health authority reports that it receives 400-500 incomplete forms each day. And in many health facilities, two trends are occurring in the laboratories - decentralization and the transition from dedicated or specialized personnel (i.e., phlebotomists) to generalized caregivers. Laboratory employees and these generalized caregivers must follow strict guidelines for handling incorrectly labeled specimens requiring rather involved procedures including submitting new requisitions and signed, written statements that reduce productivity.

A more serious consequence from the mislabeling of specimens than caregiver productivity is the quality of patient care. Consider the following:

A woman was inadvertently injected with another patient’s blood at a medical group in San Diego. A sample of her white blood cells was sent to a lab to be tagged with a radioactive isotope, to be reinjected into her bloodstream as a marker for infection. Although both the syringe and the container in which it was transported were clearly labeled for another patient, a loose piece of paper, attached with a rubber band to the outside of the syringe package showed this woman’s name. Most of the blame was placed on a radiology technician who failed to clearly read the labels. The U.S. Centers for disease control estimates that a mistake of patient identification or dosage occurs in one of every 10,000 nuclear medicine procedures. The blood and radioactive isotope are combined in a different location from where the patient receives the injection, so the CDC recommends extensive labeling and bar code scanning procedures. ^⁴

A supermarket cashier tested positive for a random drug test when she had never taken drugs, and was fired from a job where she had ten years of tenure. DNA testing proved that the urine sample used was not hers. A Baltimore hospital and Virginia laboratory were named in a $9 million lawsuit. ^⁵

Automating specimen identification would virtually eliminate these types of errors and streamline procedures. Collection list information would be downloaded to a handheld bar code reading terminal that stores each patient’s name, hospital number, lab accession number, and test orders. The handheld computers would insure only validated caregivers may access patient information. A second level of security would be applied at the patient’s room when the caregiver scans the patients’ bar coded wristband, verifying both the patient and the ordered tests. The handheld indicates the tests, appropriate tubes, and quantity of tubes required for the patient and generates bar coded laboratory labels for tube identification at the patients’ bedside. This eliminates mislabeling because the only labels available are the ones printed for that particular patient. The handheld automatically time stamps operations, providing physicians and the laboratory with an accurate audit trail that includes positive patient ID, caregiver ID, and time of collection. All completed draws are sent, via the handheld computer, back to the LIS (Laboratory Information System) for reconciliation. When you consider the number of specimens that pass through the average lab each day and the total amount of time required for manual entry, the time saved by bar coding specimens becomes very apparent.

Blood Bank. The growth in the number of autologous blood donors in recent years has provided the blood bank with increased incentive to adopt bar code and mobile handheld computing technology. The issues faced here are even more serious than in the laboratory. In the blood bank, the result of an error can often result in the loss of a patient’s life.

An elderly man died at a New York medical center when he was given the wrong blood during a transfusion mix-up. The hospital blamed two nurses who failed to follow proper procedures during the transfusion. The nurses did not match the transfusion form with the patient’s name and medical record number on the patient’s wristband. The nurses did not match the blood type with the patient’s blood group in the medical record. ^⁶

The FDA sited a large blood bank for more than 200 violations of federal blood safety guidelines including blood that was ". . . mixed up and subsequently sent out. . ." with incorrectly labeled blood types. ^⁷ Since the beginning of 1990, over 25,000 mishaps have occurred. ^⁸ There is also the most dreaded complication of blood transfusion: acute hemolytic reaction. Most of these reactions are the result of human error, such as the transfusion of properly labeled blood to the wrong person, improper identification of pretransfusion blood samples, or clerical errors occurring within the blood bank. ^⁹

When patients are admitted to the hospital, the bar coded ID number on their wristband allows virtually fail-safe matching of patient and blood. Utilizing the same security featured in the use of handhelds in the laboratory, the blood bank would be able to match the unique blood bag bar codes to the patients’ medical record number. The handheld then would record multiple sets of vital statistics per patient, transfusion start and stop times, and if there was a reaction to the transfusion and what the reaction was. All this information could be printed on thermal labels with a note to the caregiver to sign and put the labels into the patients’ chart for the doctor’s review. The completed transfusion data can then be uploaded from the handheld computer to the LIS, reconciled, and billed through the HIS (hospital information system).

Pharmacy. Patients with adverse drug reactions have to stay in the hospital an average of two extra days at an additional cost of $2,000. Overall, a typical hospital will see its costs increased to over $1 million over the course of a year due to adverse reactions. ^¹⁰ But like the blood bank, the price is often measured in terms of fatalities.

A female patient died at a Michigan hospital after the wrong dye was used in a spinal x-ray procedure. A vial of Renografin 60 was improperly used in her myelogram, although Renografin 60 is used as a dye in the x-ray of kidneys and joints, but never the spinal cord. The mix-up was attributed to the failure of medical technicians to follow procedures. ^¹¹

In the nightmare of all nightmares for a medical institution, a Boston Globe Columnist died when the a cancer institute dispensed four times the recommended dosage of a chemotherapy drug, Cytoxan. The drug caused violent episodes of vomiting and the sloughing off of her intestinal lining. In addition to the legal consequences of the mistake, the cancer institute has faced a torrent of publicity from the late Boston Globe journalist’s friends, many of whom are also journalists. ^¹²

Consistent with the laboratory and blood bank, utilization of handheld computers in the pharmacy mandate the same stringent security features to insure quality patient care. Dispensing information can be downloaded to a handheld bar code reading mobile computer that stores each patient’s name, location, and scheduled dispensing time. After scanning the patient’s bar coded wristband to validate the patient, a list displaying the scheduled medications and doses for that specific patient and time would be displayed. The medication can then be selected and scanned - providing verification that the listed medication and dose is what is being dispensed to the appropriate patient. As before, the dispensed medication data can then be uploaded from the handheld computer to the pharmacy’s main system.

Emergency. Because so many patients pass through the emergency room every year and because ER costs are so out of control, the ER is another prime area for the integration of bar-coded ID wristbands. The fast-paced environment of emergency rooms makes them perhaps the most highly prone of any department to make costly mistakes. Patients are constantly moved around and specimen mix-ups can happen easily.

A medic with a New York emergency medical service died in the trauma center of a New York hospital after a botched transfusion, when he went into shock, suffered kidney failure, and died of cardiac arrest. The blood mix-up resulted because a blood bank technologist and several intensive care nurses failed to follow established procedures. ^¹³

The combination of a patient with a bar-coded wristband and a caregiver with a bar code reading handheld computer utilizing the previously mentioned implementations is the ideal remedy for looming identification disasters.

Benefits

Although there are financial consequences to hospitals when mistakes occur, the real tragedy are the human consequences. Most medical institutions maintain that they do not have errors in the collection of medical samples or the transfusion of blood or even the dispensation of medications. Obviously, many errors do occur, and errors occur at every medical institution. Basic studies of human error in any endeavor have shown that errors occur in 3% to 5% of repetitive operations. The way to reduce errors is to improve procedures, and to implement handheld computer technology. Mobile handheld computers never get tired, stressed, or confused. They always follow procedures exactly as programmed. Where the procedure is accurately recreated in software, a medical institution can enforce procedures and internal controls on the medical technician who is using the software, thereby eliminating the possibility of committing errors. Furthermore, the common requirement of having a second medical practitioner check the work of the first can be eliminated because the computer can verify that procedures are being followed.

Positive patient identification implemented through bar coding and handheld mobile computers improves the efficiency of caregivers by allowing them to follow a logical flow rather than sorting through paper-based work orders. Patient verification and the printing of bar coded labels happen at bedside, reducing the cost of reworks by making sure of the right patient and eliminating the potential of placing the wrong label on a specimen. The handheld computers also interface to the HIS/LIS so that the collected data can be automatically integrated, saving personnel time and data entry costs.

This technology has been proven to save time and money, providing numerous benefits while reducing the cost of collecting patient data. It increases the efficiency of caregivers, minimizes error rates, collects additional information, eliminates data entry costs, reduces the time required to make data available in the HIS/LIS, and most importantly, improves the care given to patients.

^¹ Pittsburgh Post Gazette, October 24, 1993.

^² Ibid.

^³ Hartford Courant, April 11, 1995.

^⁴ San Diego Union-Tribune, October 22, 1993.

^⁵ Baltimore Sun, September 29, 1995.

^⁶ Albany Times Union, February 12, 1995.

^⁷ Reuters Health Information Services, 1996.

^⁸ USNews & World Report, 1994.

^⁹ Blood Bank of the University of Michigan, 1982, 1987, 1991, 1993, 1995.

^¹⁰ Computerworld, Inc., 1996.

^¹¹ Detroit News, September 27, 1995.

^¹² USA Today, April 7, 1995.

^¹³ Newsday, September 1, 1995.

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