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2/20/2004

Massachusetts Moves Ahead with Patient Safety Initiatives

Donna Young

Four years after Massachusetts state Senator Richard T. Moore (D-Uxbridge) introduced legislation to establish a center to coordinate statewide patient safety efforts, the state's public health department announced in January that it had received $200,000 to launch the Betsy Lehman Center for Patient Safety and Medical Error Prevention.

The center is named for a former Boston Globe health care reporter who died in December 1994 at Dana-Farber Cancer Institute in Boston after receiving a fourfold overdose of a chemotherapy agent used to treat breast cancer.

"The Betsy Lehman Center will improve patient safety and give providers the tools they need to address medical mistakes before patients are harmed," said Moore in a January 12 speech. "These errors are not intentional by any means, but we know that they are preventable."

Future funding in question. Center Director Nancy Ridley, assistant commissioner for the Massachusetts Department of Public Health, said the $200,000 was allocated from the state's tobacco settlement trust fund and added that she is aggressively seeking other sources of federal and state funding to keep the center going.

Moore called on Massachusetts Governor Mitt Romney and the state's legislature to "truly support a safer health care system" by appropriating at least $1 million in next year's budget to fund the center, and to "continue that investment well into the future."

"We cannot build a safer health system with a 'first you see it, now you don't' form of budgeting as we have witnessed with this program since it was initially authorized," Moore proclaimed. "We must commit to a sustained and significant investment in staff, resources, and funding for patient safety."

A coalition is formed. Ridley said that Lehman's highly publicized death, along with other high-profile medical errors that occurred in the state and across the country in the mid-1990s, triggered the creation in 1997 of the Massachusetts Coalition for the Prevention of Medical Errorsa public-private collaborative of more than 50 organizations, including health systems, regulators, professional health care associations, and insurers.

Several pharmacists, pharmacy groups, and the Massachusetts College of Pharmacy and Health Sciences are members of the coalition and have played an important role in the development of the organization's initiatives, she said.

Access to medications is a patient safety issue

When a patient does not have access to a needed medication or does not comply with taking a drug as prescribed, the result is a medication error, said Dennis G. Lyons, executive director of the Center for Continuing Professional Development at the Massachusetts College of Pharmacy and Health Sciences.

Medication safety incorporates more than having appropriate procedures in place to ensure accuracy with dispensing and administration, he said.

Patients must have access to drugs and be provided with information that is "understandable" to ensure proper compliance with medications, Lyons asserted.

Patients are confronting more and more barriers to appropriate medication use, such as the high cost of drug products, tighter restrictions by health plans, and a lack of time spent by prescribers on explaining drug products to patients, he said.

The recent Medicare reform legislation has "shifted the debate" about medication issues away from quality and safety to the cost of drug products, Lyons said.

"We are in a critical time," he said.

A growing number of callers to the pharmacy school's toll-free hotlineMassMedline, a project that helps residents in the state access medicationsare people who have insurance, but their plans have restricted access to needed medications, Lyons said.

The MassMedline program also includes an outreach component, which consists of pharmacist presentations to senior groups and other community organizations.

As part of the presentations, Lyons said, pharmacists encourage people to keep an accurate and complete list of medications at home and take that list with them when visiting the pharmacy or their physician.

The coalition is acting as an advisory committee for the Betsy Lehman Center, as mandated by the legislation that created the center.

The Institute of Medicine, in its 1999 report, To Err Is Human: Building a Safer Health System, praised the coalition for its aggressive efforts in compiling and publishing recommendations for safe medication practices.

Reconciling medications. The coalition, Ridley said, has collaborated with the state in developing a "reconciling medications initiative" as part of a $4.5 million Agency for Health Care Research and Quality grant awarded to Massachusetts's public health department in 2001 to study the root causes of medical errors and to devise appropriate strategies for prevention.

"Reconciling medications is a process to reduce errors and harm associated with medication issues as patients transfer from one level of care to another," said initiative Cochair Frank Federico, a pharmacist and loss prevention specialist at Risk Management Foundation, a medical malpractice insurance company serving the Harvard medical institutions.

The coalition based its concept on an ongoing initiative at Luther Midelfort Hospital in Eau Claire, Wisconsin, he said.

Some organizations refer to the concept as having a "complete medication list," Federico noted.

"It has clearly been demonstrated that not only are there errors and harm that result when medications aren't reconciled, but also, there's a certain amount of work and rework that is minimized or reduced simply by making the process more efficient," he said.

Pharmacists, Federico said, are very interested in making sure that the process of reconciling medications is done correctly, and "they can play a major role in ensuring that the medications are not only the correct medications but are appropriate for the patient."

Reconciling medications "used to be part of our practice," he said. But "as nurses have been pressured to do more with less, and as pharmacists' roles have changed as well, it sort of fell by the wayside. So now what we are trying to do is to [bring] it back into practice."

Who completes the reconciling process in an institution is "totally up to who is in the best position to do it," Federico said. "It could be the pharmacist, it could be a nurse. One institution has used pharmacy technicians with pharmacist oversight."

The idea, he added, is that the "medication list is as accurate as we could possibly get it. The whole purpose of this is to get the hospitals in Massachusetts to work together in solving a problem that we have identified as a contributor to medication errors and harm."

Ernest R. Anderson, director of pharmacy services at Lahey Clinic in Burlington, Massachusetts, said his hospital has been working on fine-tuning its medications reconciliation process over the past year.

After an initial medication history has been collected for a patient who is admitted to the hospital, he said, there is "a need to do med reconciliation every time a patient moves from one type of care to another."

For instance, Anderson explained, if a patient has been admitted to the hospital for surgery, the initial medication list must be reconciled after the patient leaves the operating room, and the patient's physician needs to decide which medications the patient should be using after surgery.

Some medications, he noted, might need to be switched from an oral to an i.v. form after surgery, or the dosage might need to be adjusted, or use of a medication should be stopped.

Reconciling of medications must occur for any patient who is transferred to the intensive care unit after surgery, Anderson added.

When a patient is discharged from the hospital, said Nancy Huff, pharmacy director at Caritas Norwood Hospital in Norwood, Massachusetts, the patient should be provided a complete list of medications and clear instructions about using the drugs.

Too often, she warned, patients leave the hospital assuming that they should use all of the new medications dispensed to them at the hospital, plus continue the medications they were taking at home before being admitted as an inpatient and end up taking duplicate therapies, which could lead to an overdose.

"If [patients] are not sent home with clear directions as to what they are supposed to take and not take, you could end up in the same mess if they go home and retake what they started with," said Huff, who chairs Caritas Norwood's reconciling medications project.

Huff said her hospital is still perfecting its medication reconciliation form.

"Right now the form is not electronic; it's a paper system," she said. "We don't have an electronic system for our nursing assessment tool, which this is going to be an offshoot of our nursing assessment tool."

The hospital has created a wallet-sized card for patients who want to carry their medications list with them, Huff said.

The card is an "ideal" tool that helps pharmacists and physicians reconcile the patient's medications during outpatient visits, she said.

Anderson said hospitals participating in the coalition's reconciling medications project do not hesitate to share ideas and "steal shamelessly from one another."

"We don't need to recreate the wheel," he said. "Let's see what's working at other places, and let's learn from each other. Let's steal each other's forms. Let's figure out what works in other places and just try it that way. Let's figure out how people have overcome barriers, and let's copy what other people have done."

Cheers. The coalition was honored last December by the Institute for Safe Medication Practices (ISMP) with a 2003 Cheers award for its reconciling medications initiative, Anderson noted.

His hospital, Lahey Clinic, and 20 other hospitals that comprise the VHA New England Collaborative, also received an ISMP 2003 Cheers award for its Medication Error Prevention Initiativea project in which the hospitals used ISMP's Medication Safety Self-Assessment Tool to measure and improve the medication-use process.

The American Society of Health-System Pharmacists (ASHP) was also honored in December by ISMP for its championing of fail-safe medication use in health systemsthe first plank in ASHP's leadership agenda.

Errors in ambulatory care. A new initiative that the Massachusetts coalition is undertaking will focus on medication errors in the ambulatory care setting, Federico said.

"We realize that there has been a significant amount of work done in the inpatient setting to address medication errors and harm, and we found that there was a need to move to the ambulatory [care] setting and develop a similar set of recommendations that could be used for the medication management outside of institutions," he said.

The coalition has formed an ambulatory care medication work group that includes consumers, physicians, pharmacists, nurses, academic researchers, regulators, and managed care plans.

The group will develop safety tips for prescribers and pharmacists, Federico said, and it is working closely with the state's board of pharmacy on the initiative to identify best practices for retail pharmacists.

The board of pharmacy is in the final stages of developing a root cause analysis for ambulatory care practices, said Chuck Young, executive director for the Massachusetts Board of Registration in Pharmacy, which it plans to share with the coalition.

As a regulator of pharmacy practice, said Young, who is a member of the coalition's board, he has recognized that "we have a lot of problems" in medication errors in the ambulatory care setting.

Participation in the coalition, he added, has been "the first chance that I've seen where regulators, hospital administrators, and practitioners that are at the shop end of the sort, can all sit together in a room and discuss frankly and honestly issues that have arisen and come up with solutions. It's been very exciting."

The coalition's other initiatives include communicating critical test results, defining accountability in patient safety, reducing restraint and seclusion use, and reducing medication errors in acute and long-term-care facilities.