I've been thinking about physicians, bar coding, and WIIFM?
Recently, while pondering why the physician community has been seemingly
immune to the bar-coding-at-the-point-of-care (BPOC) bug, I had an idea. Maybe
it's because they've been dialed in to WIIFM: not an FM radio station for
Nintendo's Wii but the abbreviation text-messaging types use to ask "What's in
it for me?"
My idea arrived while rereading Dr. Robert Wachter's May 2, 2008 blog
entitled,
Should Hospitals Install Bar Coding or CPOE First? Why I've Changed My Tune.
While asking himself the question why CPOE had gained so much more momentum
than bar coding over the past decade, the pioneer of hospitalist medicine
suggested a theory:
"In the early days of clinical IT, many of the movers and shakers were
physician-informaticists, and they had to sell the case for change (and
considerable investment) to their fellow physicians if there was to be any
hope of their hospital taking the IT leap. It is logical that they would
have deemed prescribing errors to be the main culprit; those are the ones
that they themselves had committed and witnessed." He added, "Despite their
importance, administration errors (which represented more than one-third of
all medication errors) were ignored by physicians."
Is this just another way of saying few physicians seem to have found WIIFM
in BPOC? Contrary to the stereotype, not all physicians are only concerned
about the M. Most would add a P to our abbreviation. They want answers to
"What's in it for my patients?" This is illustrated in the rest of Wachter's
May 2 musings.
It appears that during his brief participation as the keynote speaker for
The unSUMMIT for Bedside Barcoding,
Wachter caught the BPOC bug. On his flight from Austin back to San Francisco,
he wrote:
I started thinking about the big, high-profile errors I've heard about in
the last year or two, both at UCSF and nationally. And I had an epiphany. Or
maybe it was the turbulence. But here goes.
At UCSF Medical Center... virtually every terrible medication error case I
can recall in the past couple of years involved a nurse administering a
medicine.
Thinking about this drumbeat of tragedies, I tried to recall a major
medication error in the last few years that would have been prevented by
CPOE (computerized physician order entry)... and I couldn't. Not that there
aren't any, but it does seem like today's Oh-My-God-How-Could-This-Happen
med errors are now disproportionately administration, not prescribing,
mistakes.
Moreover, with everybody now on their toes about medication safety, an
errant prescription has many downstream opportunities (pharmacist, nurse,
even patient or family) to be caught before it kills.
On the other hand, there is generally nothing that stands between the busy
nurse who makes a dose calculation error or confuses a vial of heparin for
insulin--and tragedy. The nurse has only one chance to get it right, and no
safety net if she gets it wrong.
Even though the (BPOC) evidence continues to trail (CPOE), based on what I
know today, if I was a hospital ready to get into the IT game, I'd go with
bar coding first.
Anything but self-centered, the good doctor is thinking about the best
interests of his patients and their nurses.
A week later, I received the following e-mail:
TO: Mark Neuenschwander
FROM: Robert Wachter
SUBJECT: Today's JAMA
MESSAGE: Important article in support of bar coding, FYI --
Barcoded
Medication Administration--A Last Line of Defense1
I promptly read the article, and hope you will too, in which Toronto
physicians David Cescon and Edward Etchells conclude a compelling case for
BPOC with a plea: "Nurses have long served as the last line of defense against
medication errors. The health care system must wait no longer to provide them,
and all patients, with the systematic safety net that they deserve."
While I applaud these doctors on both sides of the border for seeing what's in
BPOC for others, I also appeal to them to take another look at what's in it
for them. The most overlooked value of BPOC, in my opinion, is its
contribution for supplying physicians with more accurate
medication-administration records (MAR). When assessing patients' needs, do
not doctors utilize MARs to determine whether to continue, discontinue, or
amend drug therapies? Too often medications are charted long after they have
been administered, interruptions have occurred, and memories have lapsed. Some
administrations are charted in error. Others are not charted at all. What
physician wants to write orders based on inaccurate MARs?
While none of the above MDs overtly indicated the value of BPOC to physicians,
the Canadians did note that "BCMA automatically generates an accurate
electronic medication administration record, improving both patient care and
hospital invoicing." I would add that it improves physicians' practice of
medicine.
And, while I'm with the docs in seeing the WIIFM of CPOE, I'd like to suggest
that no CPOE software is capable of healing inaccurate MARs. There is more
WIIFM in BPOC than has met the average physician's eyes.
BPOC's got SIIFE--something in it for everyone.
What do you think?
Mark Neuenschwander a.k.a. Noosh
mark@hospitalrx.com
1. JAMA. 2008;299(18):2200-2202 (doi:10.1001/jama.299.18.2200) P 2201
Now for some news...
- What Comes First? Second? Third?
"Our whole initiative was driven from the board on down as a patient safety
issue," says William McClatchey, M.D., the hospital's chief medical
informatics officer. That's why the hospital tackled medication
administration first, CPOE second, decision support third and clinical
documentation last, he says. Executives concluded that this sequence would
yield the most rapid (and significant) patient safety gains and build
momentum. Source:
Health Data Management
- View online: Interview with Julie Thao, RNC and Charles Denham, MD,
on The 5 Rights of the Caregiver
At The unSUMMIT for Bedside Barcoding Mark Neuenschwander, cofounder of The
unSUMMIT, interviewed Julie Thao, an OB nurse from Madison, WI who received
national notoriety when she was involved in a medication error that took the
life of a 16-year-old mother. What's a hospital to do with a caregiver who
becomes a patient during such a catastrophic event? Listen to the interview
at pointofcareforum.com.
Noosh note: This was the highlight of The unSUMMIT for me!
-
Patient sues Saint Agnes Medical Center over mix-up:
Attorney says his client received wrong biopsy results
For four months, Edward Hobbs believed he might die. A biopsy on his lung
had come back positive for cancer, and he had surgery to remove a portion of
his lung. But it was all a mistake. He didn't have cancer. Doctors didn't
tell him they were wrong until two months after the December 2006 surgery.
Hobbs and his wife, Christina Hobbs, are now suing doctors involved in his
care, Saint Agnes Medical Center, and its pathology department. The medical
malpractice lawsuit, filed in February, alleges that Hobbs' cancer diagnosis
and surgery were based on a biopsy, or tissue sample, that belonged to
another patient. Source:
Fresno Bee,
May 19, 2008
Noosh note: Errors like these will keep "Improving patient
identification" at the top of The Joint Commission's National Patient Safety
Goals. The fact that it has been the number one goal for the past five years
indicates that we are not making much progress. I still don't understand why
TJC is dragging their feet on pressing hospitals to employ BPOC.
- AJHP adds new column to share experiences with information technology
This column--Informatics Interchange--is the newest method for pharmacists
to learn from their colleagues' experiences with information technology.
Health systems across the country are currently faced with evaluating,
selecting, implementing, and monitoring numerous technologies. This column
will provide a forum to share challenges and successes with pharmacy
informatics and technology issues and discuss how technology has affected
the medication-use process. Specifically, the column will provide practical
solutions and insights to the use of information technology in pharmacy
practice. Source: American Journal of
Health-System Pharmacy, Vol. 65, Issue 11, 1012-1014
Noosh note: The epicenter of pharmacy informatics has moved from HIMSS to
ASHP where it belongs. Hats off to Karl Gumper for his great leadership.
- Kaiser learns from tragic medical errors
Three years ago ABC7 News reported on a series of deaths at Kaiser hospitals
in the South Bay. These incidents prompted changes, for hospitals statewide.
Among other significant measures, Kaiser is investing point-of-care bar-code
systems. The health system is on track to have all of its Northern
California hospitals using bar coding by 2010. Source:
ABC7 - San Jose, May 26, 2008
Noosh note: It is encouraging when the media stays tuned, follows up, and
tells the rest of the story. This is good news.
- Central Florida hospital cited in transfusion error
The Orlando Regional Medical Center was cited by the state after a patient
died in March following a transfusion error. The hospital said that the
report by the Agency for Healthcare Administration does not directly link
the death to the transfusion error. The hospital did say, however, that new
procedures have been put in place to prevent this type of incident from
occurring again. The state is asking for policy and procedure revisions
related to the storage, retrieval, logging and verification of blood.
Source: WKMG
Orlando, May 23, 2008
Noosh note: We frequently hear about how 7,000 preventable MADs
(medication-administration deaths) occur each year. Anyone know how many
deaths occur each year from blood errors? I'd love to hear from you if you
do.
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