RANCHO MIRAGE, CA, November 9, 1998 -- If you are one of the 30 million Americans admitted to a hospital each year, getting your medicine should become a lot safer once the findings of research reported today at an international patient safety conference in Palm Springs, California, are implemented nationwide. And, computers will play a major role according to the research, which included:
* Replacing hand-written medication orders with a computerized physician order entry system at Brigham and Women's Hospital in Boston that led to an 86 percent reduction in serious medication errors that could cause injury,
* Implementing a new computerized system for detecting potentially dangerous drug combinations at Barnes-Jewish Hospital in St. Louis that resulted in a 66 percent reduction in potentially unsafe combinations with cisapride, a gastrointestinal drug,
* Reconfiguring a machine used by patients to self-administer their pain medication, thereby eliminating 55 percent of the programming mistakes made by hospital staff, according to University of Toronto researchers, and
* Developing a first-of-its-kind computer program that predicts error potential -- or "cognitive toxicity" -- due to medication names sounding or looking alike, the cause of one in four reported medication errors in the U.S.
Still, computers used to catch mistakes may not be mistake-free themselves, as researchers at the Cleveland Clinic Foundation discovered. They used computers with radiation therapy equipment to verify compliance with pre-set parameters and essentially eliminated serious errors. Of remaining minor errors, about 15 percent were related to the safety system itself. That's because some human operators appeared to trust the computer safety system's accuracy more than their own common sense. In some cases, minor data mistakes were allowed to persist in the computer safety system that might have been caught on hand-written data entry forms.
Demonstrating that humans are just as important as computers in making health care safer are the findings of two studies also reported today:
* Placing a clinical pharmacist on an intensive care unit patient care team that resulted in a 77 percent reduction in preventable adverse drug events at Massachusetts General Hospital, and
* Standardizing medication orders, eliminating "look-alike" medications, and revamping medication processes that led to a 50 percent reduction in medication errors at Hermann Hospital in Houston.
Opening yesterday and continuing through tomorrow, the conference -- Enhancing Patient Safety and Reducing Errors in Health Care -- is being held at the Annenberg Center for Health Sciences at Eisenhower Medical Center in Rancho Mirage. It was convened by the American Association for the Advancement of Science, the Annenberg Center for Health Sciences, the Joint Commission on Accreditation of Healthcare Organizations, the National Patient Safety Foundation at the AMA, and the U.S. Department of Veterans Affairs.
Additional support for the conference is coming from the Agency for Health Care Policy and Research, the American Hospital Association, the American Society of Health-System Pharmacists Research and Education Foundation, Pfizer Inc., Pharmacia & Upjohn Inc. and the Robert Wood Johnson Foundation. The conference comes after a pathbreaking patient safety meeting held at the Annenberg Center in October 1996.
The conference closely follows the October 28, 1998, publication by the Journal of the American Medical Association of an editorial calling for new approaches in promoting patient safety. The authors wrote: "To solve a problem, that problem must first be recognized. Unfortunately, error in medicine is real and common. The good news is that we have recognized the problem of error in medicine. The next step has been to go public with the problem, to study it, and to create methods to solve it. Many groups are now addressing this. It will then be necessary to implement methods that are found likely to reduce the probability of error." (http://www.ama-assn.org/sci-pubs/sci-news/1998/snr1028.htm#jed80080)
The above story is based on materials provided by American Association For The Advancement Of Science. Note: Materials may be edited for content and length.
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