First Do No Harm

July 5, 2005
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GRAND RAPIDS — A patient has just come out of a minor surgery. The physician prescribes the painkiller Vicodin to treat any pain the patient may suffer during recovery. The hastily handwritten prescription is handed off to a nurse, who passes the slip off to a unit secretary. The secretary glances at the nearly illegible prescription slip and — based on her knowledge of this physician's handwriting, and of the procedure he has just undertaken — is able to correctly identify the ordered medication as Vicodin. She types up the prescription and faxes it to the pharmacy.

The pharmacist looks at the order and takes a few steps over to the shelf where Vicodin is stored. The phone rings. He hopes his assistant will pick up. She has recently moved the T-though-V shelf to make room for more medications, so he has some trouble finding the prescribed drug. He searches for a moment and sees the familiar package — Vicodin is a frequently prescribed painkiller. The phone is still ringing; his assistant is nowhere in sight. Distracted and slightly annoyed, he reaches to grab the pill bottle, and accidentally knocks several containers off the shelf, including the Vicodin. He hastily picks them up and hurries to answer the phone, as he counts out the appropriate number of tablets.

The patient, now at home, begins to feel his local anesthetic wearing off. He rips the indications and warnings slip off of the pharmacy envelope and pulls out the pills. He glances at the label, learning that he should take two Vicodin every six hours as necessary. He pours a glass of water and swallows two pills.

What the patient doesn't know is that he has just taken two Visicol tablets. Visicol is a laxative. It happened to be stored next to Vicodin on the pharmacy shelf.

That is a hypothetical example, but it is based on an actual case reported to U.S. Pharmacopeia, an organization that sets standards for pharmaceutical and health-care products sold in this country.

These mix-ups do happen; the National Academy of Science's Institute of Medicine estimated in 2000 that between 44,000 and 98,000 Americans die each year because of preventable medical errors. The good news for patients is that these errors are becoming more difficult to make.

Hospitals across West Michigan, and across the nation, are putting a renewed focus on instituting policies and adopting technologies with one goal in mind: increasing patient safety.

Any hospital's safety watchdog is its risk management department. Hospital risk managers often combine experience in clinical care with an advanced knowledge of medical law. Many — such as Spectrum Health's Bridget Tucker Gonder and Metropolitan Health's Christine Lawrence — began their careers in nursing and went on to earn law degrees.

Local risk managers told the Business Journal that over the years, the focus of hospital risk management has shifted away from reacting to "negative outcomes," such as medication errors, patient injuries or preventable deaths. Now risk managers spend much more time thinking, "What if?" and creating policies to prevent medical error.

"The key message on risk management, from my perspective, is that we know errors happen," said John Collins, M.D., chief quality officer at Saint Mary's Health Care. "We want to minimize the risks of errors through education. We want to identify every place we can where they are occurring or potentially occurring. We want to investigate those thoroughly and we want to do it in a way that looks at the systemic problem, rather than identifying who to pin the blame on. Basically, when something bad happens, my thinking goes immediately to 'How did the system fail?' rather than 'Why did that damn nurse give that medication to that patient?'"

"When errors happen, it typically isn't the fault of an individual. It's usually a process error or a process failure," said Spectrum's Tucker Gonder. "So we'll do what we call a 'root cause analysis,' to go back, look at the process, correct those areas where the (error occurred)."

Collins used the metaphor of a crime scene to describe how Saint Mary's handles a report of a medical error. They cordon off the area where the event took place and examine the process "in minute detail," including interviews with all involved personnel.

"The police force is the risk managers who go out and investigate the scene of the crime, so to speak, and smell out where the issues are, then bring it back and say, 'What do we need to do to fix this system to make sure this doesn't happen?'" said Collins.

Another change in the evolution of risk management is a willingness to readily admit when errors have occurred and to fully disclose all information surrounding the error.

"When errors do occur, not only do we investigate, but as soon as we know what's going on, we get the patient and the patient's family, we get everybody together and we disclose. We tell them everything we know," said Collins.

"There's nothing worse for patients and their families than not knowing what happened — to have that sense that something went wrong and not to know," said Barb Van Patten, Saint Mary's director of risk management.

"The old risk management approach would have been to avoid, perhaps, coming out and dealing with patients and families who have had bad outcomes," said Tucker Gonder. "And so you would kind of wait for them to come and find you, or wait to hear from their attorney. That is not our approach. Our approach here is very proactive. In fact, members of my staff will go to a patient's room after we discover the advent of an adverse outcome, introduce themselves, give (the patient) a business card and start to begin a dialogue. That has a huge impact on how the patient perceives us an organization."

It can also have an impact on the hospital's finances.

"I would say we're able to resolve a large percentage of our cases without litigation," she said. "So you cut out the attorney fees, you cut out the rancor and the emotional turmoil of going through the litigation process. And it's good for the bottom line."    

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