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Pittsburgh Hospitals Band Together to Reduce Medication Errors

Donna Young

In a pursuit to eliminate medication errors and hospital-acquired infections, about 40 competing hospitals in southwestern Pennsylvania have agreed to share and compare sensitive information.

The hospital coalition, known as the Pittsburgh Regional Healthcare Initiative (PRHI), received a $5 million demonstration project grant from the Agency for Healthcare Research and Quality (AHRQ) to evaluate the effectiveness of reporting systems in reducing medical errors and improving patient safety.

Robert Weber, chair of the pharmacy and therapeutics (P&T) department at the University of Pittsburgh and the project’s coprincipal investigator for medication error reporting, said hospitals in the coalition are "committed to perfect patient care."

"The outcome of the [AHRQ] grant will be that we have reporting systems that are effective, the information is usable, and the information is translatable to practice," he said. "And that through the use of reporting systems, we develop a systems approach to patient safety using a variety of different quality improvement techniques across the region."

A history of improvement. U.S. Treasury Secretary Paul H. O’Neill helped to establish PRHI in the late 1990s when he was chief executive officer for the Pittsburgh-based aluminum giant Alcoa Inc. O’Neill believed that the worker-safety concepts established by Alcoa could be used by the health care industry to improve patient safety, Weber said.

O’Neill based his company’s concepts on the Toyota Production System, a quality improvement model in which specific rules guide the design, operation, and improvement of every activity, connection, and pathway for every product and service. Each rule includes a built-in experiment to signal problems automatically.

Edward I. Harrison, PRHI’s director of patient safety, said five of the coalition’s hospitals are piloting the Toyota model.

Before more PRHI member hospitals adopt the Toyota approach, a system that takes several years to learn and implement, they must focus on common ways to report errors, Harrison said.

Common reporting. To report data on hospital-acquired infections, PRHI is using the National Nosocomial Infections Surveillance system developed by the Centers for Disease Control and Prevention.

For recording, classifying, and evaluating medication errors, the coalition is using the MedMARx system developed by the United States Pharmacopeia (USP). MedMARx is a Web-based database for hospitals to anonymously report and track medication errors in a standardized format.

The system, available at an annual cost of $2195–$7000 per institution, was first used in 1998 by about 50 hospitals. That number of participants has since grown 10-fold, said MedMARx creator Diane D. Cousins, a pharmacist and USP’s vice president of practitioner and product experience.

USP became involved in medication error reporting, Cousins said, because "we wanted to learn about those instances where a product’s labeling, packaging, or naming could be contributing to errors so we could set standards."

USP, in conjunction with the American Society of Health-System Pharmacists and several other groups, helped establish the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) in 1995. Since then, NCCMERP has developed definitions for medication errors, a severity index that classifies medication errors on the severity of the outcome to the patient, and a taxonomy to catalog errors.

Requests from hospitals and other health care groups wanting to know how they could, while remaining anonymous, use NCCMERP’s definitions and taxonomy to compare medication-error information with data from other hospitals prompted USP to develop MedMARx, Cousins said.

Hospitals using the system can run reports based on their own data, she said, and prepare spreadsheets, charts, graphs, and custom-built reports anytime using data reported anonymously from other hospitals.

Cousins said PRHI’s collaborative project is "fascinating" and "far ahead" of other hospitals that subscribe to MedMARx.

Projects similar to PRHI’s are underway at the Cleveland Clinic of Ohio and the Northern Metropolitan Hospital Association of New York, Cousins said, but PRHI’s project is the most advanced.

"It’s interesting because these are hospitals that are actually competitive in their local areas. . . . [But] they are above all that in trying to work toward improving patient care and patient safety through the sharing of information through the MedMARx tool," she said.

Advantages of cooperation. The agreement to share regional data among hospitals in the PRHI project, Cousins said, will help those hospitals learn from each other in a proactive way.

"In other words, they don’t have to wait to have an event within their hospital. They’ll be able to learn from other hospitals [about] the unfortunate experiences," she said.

Hospitals in the project have been divided into five distinct groups in which information about reported medication errors is discussed. Field administrators report the outcomes from the discussions to PRHI’s advisory committee.

Peter D. Hallisey, clinical pharmacy operations manager for Jefferson Regional Medical Center, one of the hospitals participating in the PRHI project, said the MedMARx system has forced the local hospitals to adopt a common language and a common database.

"Most hospitals were doing things in their own way and using their own definitions," he said. "The wonderful thing about MedMARx is that it forces everybody to be on the same page."

Jefferson Regional was one of the first hospitals in the PRHI project to be online with MedMARx, Hallisey said.

"Fortunately at Jefferson, we’ve had a strong commitment from leadership," he said. "It’s a certain testament to our leadership to say that this is very important to us." But the system is only a "tool and is not going to solve everything," he added.

"It’s not going to cure your problems, your issues," Hallisey said. "It’s going to identify them, but you have to take care of them. But if you don’t know your problems, you can’t solve them."

Hallisey said he uses the system to help identify problems that contribute to errors, such as a drug’s packaging or name.

"I use it when we are bringing new drugs on board for our P&T [committee]" to consider, he said. "I’ll check to see if any errors have been reported with that drug just to see what’s out there. I can know if there is some difficulty in the use of the drug, like look-alikes; how it’s used; how it’s packaged. There’s a lot of very positive and useful information in the system."

MedMARx also captures information about what actions a hospital took in response to an error, USP’s Cousins said.

"So, if they made a policy change or they changed their computer in a way that changes their [medication-order] entry requirements, you’ll see this come out in the MedMARx data," she said. "It’s a way of thinking about error that never before has been vetted. It’s a way that gets [hospitals] to think about the types of errors that they are experiencing and the causes of those errors."

NCCMERP and the MedMARx system consider that errors can occur anywhere in the medication-use process, from prescribing a drug to monitoring a patient after drug administration, Cousins said. Hospitals can also report potential errors—errors that are intercepted before reaching patients—using the MedMARx system.

Pittsburgh Mercy Uses Anonymous Error Hotline

To encourage people to report medication errors, Pittsburgh Mercy Health System established an anonymous hotline last year through which physicians, nurses, pharmacists, and other hospital employees can report events.

Susan Hern, Pittsburgh Mercy’s risk management director, said her organization wanted to "promote people reporting events, but not necessarily feeling like they are reporting their peers or their coworkers." The health system also removed the signature requirement from its medication-error reporting form.

In addition, hospital employees no longer have to "get bogged down with why the incident occurred," Hern said, "because that has nothing to do with" the person who is reporting the error. "You just need to report what happened, what the error was, what you noted, and if you knew of anything that happened to the patient," she said.

An anonymous report triggers an investigation, Hern said. After reviewing the case, the hospital enters the information into the MedMARx system, she added.

JoAnn V. Narduzzi, a physician and Pittsburgh Mercy’s vice president of academic affairs, said her health system did a lot of preparation and education before it instituted the hotline.

"It took about a month or six weeks to [educate] the nursing units, to notify the physicians, to put up the signs, to get the hotline running," she said. 

The health system created the hotline, Narduzzi said, to provide employees with a "blame-free culture for reporting medication errors."