Hospitals Share Strategies for Preventing Errors

ByABC News

July 20, 2006 — -- The Institute of Medicine released a report on medication errors that found more than 1.5 million people are harmed each year by these mistakes.

The report calls for doctors to use electronic prescriptions by the year 2010 as one way of eliminating errors. To read the IOM's guildelines for avoiding medication errors click here.

To find out what some hospitals are already doing to prevent mistakes, the ABC News Medical Unit contacted 14 of the top hospitals across the country, as ranked by US News & World Reports. The information was provided by each hospital and is not comprehensive or all inclusive.

1. Johns Hopkins Hospital, Baltimore

I SEE YOU: The system uses electronic tracking of patient medications, called medical reconciliation, when they are transferred from the intensive care unit (ICU) to another area of the hospital. If the medicine they were given in the ICU does not match the medicine they are given in the new unit, the doctor is alerted of the error.

2. Mayo Clinic, Rochester, Minn.

SAFETY CULTURE: Mayo has systems in place that encourage, support and reward the reporting of errors. "You can't fix what you can't find," said Dr David Herman, Chair of the Clinical Practice Committee.

3. Cleveland Clinic

E-WARNING: When prescriptions are entered into computers, the system warns doctors of possible drug interactions with other medications already taken by the patient.

4. Massachusetts General Hospital, Boston

SMART PUMPS: The hospital uses smart infusion devices, computerized machines that have built-in drug libraries to ensure that patients are given the correct dosage of IV medication.

5. UCLA Medical Center, Los Angeles

READ EASY: Simply using a larger font on IV bag labels and patient wristbands makes it less likely that a nurse will give the patient an incorrect drug.

6. New York-Presbyterian Univ. Hospital of Columbia and Cornell

DON'T MISS A THING: Electronic tracking of near misses, most of which are medication issues, allows the hospital to identify patterns and make improvements that can prevent actual mistakes from happening.

7. Duke University Medical Center, Durham, N.C.

MARCHING ORDERS: The Chief Patient Safety Officer (a new position created 18 months ago) makes rounds to different hospital units, looking for medical errors and reports directly to the hospital CEO.

8 Barnes-Jewish Hospital/ Washington University, St. Louis

PATIENT POWER: Patient safety posters hang in every hospital room and encourage patients to ask more about their medications and challenge any caregiver who they feel is not providing safe care.

9. University of California, San Francisco Medical Center

EXEC CHECK-UP: Hospital leaders make unannounced visits with patients to ask about any medication or other safety issues that may have occurred. They also observe that proper medication protocols are followed on the floors.

10. University of Washington Medical Center, Seattle

NO MORE FREEBIES: The medical center has stopped giving out medication samples. Sometimes the free drugs go undocumented on patient medication lists and are a potential source of medication errors.

11. Brigham and Women's Hospital, Boston

E-FFECTIVE: The hospital has been using computerized prescription writing since 1994. Researchers studying the system showed it reduced serious medication errors by 55 percent.

12. University of Michigan Hospitals and Health System, Ann Arbor, Mich.

X-RAY VISION: A system called ValiMed uses ultraviolet light to check the concentration and chemical makeup of IV solutions mixed by pharmacists, a process prone to error especially while dosing medications for kids.

13. Stanford Hospital and Clinics, Calif.

CODED CAPSULES: All pill packages are bar coded for security allowing nurses to match the barcode on a patient's wristband to that on the pill.

14. University of Pittsburgh Medical Center

ROMEO THE ROVING ROBOT: A robotic arm in the pharmacy sorts out the patients' pills and Romeo, a robot, delivers the medications to the various floors. Romeo even knows how to call the elevator and to watch out for small children in hallways.

Dr. Archana Reddy and Michael I. Silverman of the ABC News Medical Unit contributed to this report.

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