Robin Tricoles

Last summer, 17 infants mistakenly were given incorrect doses of the blood-thinning medication heparin during their stay at a hospital in Corpus Christi, Texas. Two of those infants died.

Thousands of medication errors, including the ordering, dispensing and monitoring of medication, occur each year in hospitals throughout the country. Several studies in recent years have shown that injuries resulting from adverse drug events (ADEs) account for up to 41 percent of all hospital admissions and more than two billion dollars annually in inpatient costs.

Whether a patient is an infant, child or adult, the potential for medication errors begins as soon as a patient reaches the hospital and continues well after discharge.

“Medication errors often start when the patient comes to the emergency room,” says Sandeep Sachdeva, MD, clinical assistant professor at University of Washington Medical Center in Seattle. “Patients usually don’t carry a detailed list of the drugs they’re taking. If they come in late at night, it may not be possible for us to get an alternative list.”

That’s why it’s important for drug reconciliation to begin at the time of arrival, Dr. Sachdeva says. “In my opinion, medication reconciliation is a dynamic process, and medication reconciliation is a daily process. When patients come into the hospital, certain medications automatically get changed to the medications that are available in hospitals, and anytime there is a change in medications, it’s an opportunity for an error.”

Opportunities for Error

Even if a patient arrives with a full medication list, once he or she transfers from one hospital unit to another or is discharged, the opportunity for errors increases exponentially, says Julia Wright, MD, director of hospital medicine at University of Wisconsin Hospital and associate professor of medicine at The University of Wisconsin School of Medicine and Public Health in Madison, Wis.

“What providers have to remember is that there are multiple stages at which mistakes can be made,” says William Basco, MD, director of general pediatrics at the Medical University of South Carolina in Charleston, S.C. The physician or nurse practitioner can make a mistake writing the order; a nurse can misread the order; a pharmacist can incorrectly prepare the order; and a floor nurse can make a mistake drawing up the medication or delivering it, Dr Basco explains.

What’s a Hospitalist To Do?

Although the opportunities for medication errors are many, Dr. Basco says hospitalists should take several steps to mitigate medication errors. First, he says, limit verbal orders for drugs. Instead, write the order out, print legibly and refrain from using abbreviations. He suggests writing out numbers and placing them inside parentheses after the corresponding numeral.

“It’s important to write out medications that could be confused with the abbreviations of another medication, and avoid shorthand notations that can be confused with a number when it’s actually a letter,” Dr. Wright says.

Second, avoid trailing zeros. “If you want to give 10 ml of something, write it as 10 and spell out ml, not 10.0,” Dr. Basco says. “Don’t use unnecessary decimal places, especially when the order is faxed. A 10.0 could be read as 100 if the decimal point doesn’t come across clearly. That’s how you get a 10-fold dosing error.”

Additionally, the patient’s weight should be checked carefully and rechecked, especially when ordering riskier drugs, such as anti-coagulants and narcotics. “Our hospital pharmacy requires a weight on every drug order, so they can do calculations on whether the dose is appropriate,” Dr. Basco says. “They are requiring us to write down the drug that we want to deliver and its dose, as well as the milligram per kilogram per dose we want to deliver, so they can double check whether we’ve done our dosage calculation properly.”

Computers to the Rescue

More and more hospitals are moving toward electronic recordkeeping, including computerized physician order entry, also known as CPOE. “Although electronic records won’t eliminate errors, they tend to reduce them, especially when they include decision support,” Dr. Sachdeva says. “Decision support means that this is a ‘smart’ program that can look at the dose you ordered and tell you if the dose is correct based on the patient’s weight. It also scans the other medications that the person is on and make sure there are no allergies or potential drug interactions. Or, it can even disallow you ordering drugs that it knows will interact or know will cause allergies. The system won’t let you.”

For those hospitalists still required to write out orders, Randy Ferrance, DC, MD, a dual boarded internal medicine and pediatrics hospitalist at Riverside Tappahannock Hospital in Tappahannock, Va., says multiple checks and balances, from the time the drug is ordered to the time the patient receives the drug, are essential for reducing errors. “We write the order for the expected dosage per kilo and then the charge nurse checks our math, and then the pharmacist checks not only the math, but the expected dosage for the patient,” Dr. Ferrance says. Understanding the proper dosing range for specific drugs, he adds, is as crucial as is taking into account renal function.

Check with the Pharmacist

More hospitals are including pharmacists in their multi-disciplinary rounds, says Brian Bossard, MD, founder and director of Inpatient Physician Associates in Lincoln, Neb.

“We have a single pharmacist who works with each of our teams and functions as a liaison with the rest of the pharmacist staff in the hospital,” Dr. Bossard says. “This pharmacist reviews the medication list of each of our patients and focuses on patient safety initiatives, drug interactions and cost. The pharmacist writes up the verbal order after he talks to us, so there is no delay in getting the order on the chart. That, I think, goes a long way, in preventing drug-drug interactions that can lead to problems. Really, every day there are circumstances that are identified by the pharmacist that we change, so every day we’re seeing the benefits of this relationship.”

Dr. Bossard says his group has a second pharmacist who provides requested educational information on a day-to-day basis, in terms of article and literature reviews. “It’s a great relationship,” he says. “They love to do that, and we love the information that they get for us.”

Work as a Team

Sondra May, PharmD, medications safety coordinator at the University of Colorado Hospital, says teamwork is the best way to avoid errors. “This would include the pharmacist who would determine appropriate in-house drug therapy, whether that would be determining dosage or specific drugs for specific patients’ needs. It would include making sure they’re providing sufficient information to the nurse at the bedside,” Dr. May says. “I think one of the biggest contributing factors to medication errors is poor communication.”

Dr. Sachdeva agrees direct communication is vital.

“I think hospitalists are in a unique position because we interact with almost everyone who cares for the patient,” Dr. Sachdeva says. “When I’m working, I’m talking continuously with the nurses. I think it’s important to have an open dialogue. I’ve learned that if I make a change, whether it’s on paper or on the computer, if I talk to the nurse, there is more chance it will happen earlier and it will happen correctly.”

When Errors Occur

Early detection of errors is imperative. “You want to make sure patient monitoring is frequent and specialized to the drugs they’re receiving,” Dr. May says.

If an overdose occurs before an error is detected, it’s important to strategize the treatment based on the error in question. Treatment depends on how much drug the patient received and what specific drug was given in error, Dr. May explains.

“Many hospitals have a rapid response team that will go to the bedside of patients who are showing signs of acute change in their condition, including overdoses,” Dr. Bossard says. ”The response team will assess that patient immediately and then contact the primary care physician or the hospitalist to address those issues. On the process management side, each sentinel event is reviewed in exceedingly fine detail, so processes can be adjusted and made safer in the future.”

In fact, more hospitals are creating an environment where it’s OK to admit that you’ve made a mistake. “We need to move away from blame and realize that these are patient safety issues about which we all need to be honest,” Dr. Basco says. “Part of that means full disclosure to the patient once you detect that an error has occurred. There’s no benefit to you or from a medical-legal standpoint of trying to keep it hush-hush. In fact, there’s a lot of evidence that disclosing [the error] early is beneficial.”

The Usual Suspects

A few classes of drugs are considered especially risky, Dr. May says, including narcotics, anticoagulants and insulin. These drugs aren’t necessarily involved in medication errors at a higher frequency, but they receive a lot of attention because, when an error does occur with these medications, the outcome tends to be more serious, she says.

Anti-epileptic agents, chemotherapeutic agents, and immuno-suppressants, especially in patients who have undergone transplants, can be risky. “What may be a therapeutic level for one patient may not be for a transplant patient,” Dr. Wright says.

Dr. Ferrance says he finds narcotics to be the riskiest class of drugs, especially in post-operative patients. “The dosing range is so wide to begin with,” he says, “Surgeons are afraid of not treating pain adequately, and they’re afraid of an overdose.”

Last but Not Least

A known-yet-underrepresented problem is medication reconciliation from inpatient to outpatient and vice versa. Studies clearly show that post-discharge telephone calls and home visits identify problems in medication dosing and compliance, according to Dr. Bossard. “Systems really need to be in place to facilitate this level of service, both when the patient comes into the hospital and after they’ve been discharged.” TH

Reference

1. The Journal of the American Medical Association. Medication errors continue even in highly computerized hospital. ScienceDaily. www.sciencedaily.com/releases/2005/05/050524101312.htm Published May 24, 2005. Accessed September 30, 2008.

Last summer, 17 infants mistakenly were given incorrect doses of the blood-thinning medication heparin during their stay at a hospital in Corpus Christi, Texas. Two of those infants died.

Thousands of medication errors, including the ordering, dispensing and monitoring of medication, occur each year in hospitals throughout the country. Several studies in recent years have shown that injuries resulting from adverse drug events (ADEs) account for up to 41 percent of all hospital admissions and more than two billion dollars annually in inpatient costs.

Whether a patient is an infant, child or adult, the potential for medication errors begins as soon as a patient reaches the hospital and continues well after discharge.

“Medication errors often start when the patient comes to the emergency room,” says Sandeep Sachdeva, MD, clinical assistant professor at University of Washington Medical Center in Seattle. “Patients usually don’t carry a detailed list of the drugs they’re taking. If they come in late at night, it may not be possible for us to get an alternative list.”

That’s why it’s important for drug reconciliation to begin at the time of arrival, Dr. Sachdeva says. “In my opinion, medication reconciliation is a dynamic process, and medication reconciliation is a daily process. When patients come into the hospital, certain medications automatically get changed to the medications that are available in hospitals, and anytime there is a change in medications, it’s an opportunity for an error.”

Opportunities for Error

Even if a patient arrives with a full medication list, once he or she transfers from one hospital unit to another or is discharged, the opportunity for errors increases exponentially, says Julia Wright, MD, director of hospital medicine at University of Wisconsin Hospital and associate professor of medicine at The University of Wisconsin School of Medicine and Public Health in Madison, Wis.

“What providers have to remember is that there are multiple stages at which mistakes can be made,” says William Basco, MD, director of general pediatrics at the Medical University of South Carolina in Charleston, S.C. The physician or nurse practitioner can make a mistake writing the order; a nurse can misread the order; a pharmacist can incorrectly prepare the order; and a floor nurse can make a mistake drawing up the medication or delivering it, Dr Basco explains.

What’s a Hospitalist To Do?

Although the opportunities for medication errors are many, Dr. Basco says hospitalists should take several steps to mitigate medication errors. First, he says, limit verbal orders for drugs. Instead, write the order out, print legibly and refrain from using abbreviations. He suggests writing out numbers and placing them inside parentheses after the corresponding numeral.

“It’s important to write out medications that could be confused with the abbreviations of another medication, and avoid shorthand notations that can be confused with a number when it’s actually a letter,” Dr. Wright says.

Second, avoid trailing zeros. “If you want to give 10 ml of something, write it as 10 and spell out ml, not 10.0,” Dr. Basco says. “Don’t use unnecessary decimal places, especially when the order is faxed. A 10.0 could be read as 100 if the decimal point doesn’t come across clearly. That’s how you get a 10-fold dosing error.”

Additionally, the patient’s weight should be checked carefully and rechecked, especially when ordering riskier drugs, such as anti-coagulants and narcotics. “Our hospital pharmacy requires a weight on every drug order, so they can do calculations on whether the dose is appropriate,” Dr. Basco says. “They are requiring us to write down the drug that we want to deliver and its dose, as well as the milligram per kilogram per dose we want to deliver, so they can double check whether we’ve done our dosage calculation properly.”

Computers to the Rescue

More and more hospitals are moving toward electronic recordkeeping, including computerized physician order entry, also known as CPOE. “Although electronic records won’t eliminate errors, they tend to reduce them, especially when they include decision support,” Dr. Sachdeva says. “Decision support means that this is a ‘smart’ program that can look at the dose you ordered and tell you if the dose is correct based on the patient’s weight. It also scans the other medications that the person is on and make sure there are no allergies or potential drug interactions. Or, it can even disallow you ordering drugs that it knows will interact or know will cause allergies. The system won’t let you.”

For those hospitalists still required to write out orders, Randy Ferrance, DC, MD, a dual boarded internal medicine and pediatrics hospitalist at Riverside Tappahannock Hospital in Tappahannock, Va., says multiple checks and balances, from the time the drug is ordered to the time the patient receives the drug, are essential for reducing errors. “We write the order for the expected dosage per kilo and then the charge nurse checks our math, and then the pharmacist checks not only the math, but the expected dosage for the patient,” Dr. Ferrance says. Understanding the proper dosing range for specific drugs, he adds, is as crucial as is taking into account renal function.

Check with the Pharmacist

More hospitals are including pharmacists in their multi-disciplinary rounds, says Brian Bossard, MD, founder and director of Inpatient Physician Associates in Lincoln, Neb.

“We have a single pharmacist who works with each of our teams and functions as a liaison with the rest of the pharmacist staff in the hospital,” Dr. Bossard says. “This pharmacist reviews the medication list of each of our patients and focuses on patient safety initiatives, drug interactions and cost. The pharmacist writes up the verbal order after he talks to us, so there is no delay in getting the order on the chart. That, I think, goes a long way, in preventing drug-drug interactions that can lead to problems. Really, every day there are circumstances that are identified by the pharmacist that we change, so every day we’re seeing the benefits of this relationship.”

Dr. Bossard says his group has a second pharmacist who provides requested educational information on a day-to-day basis, in terms of article and literature reviews. “It’s a great relationship,” he says. “They love to do that, and we love the information that they get for us.”

Work as a Team

Sondra May, PharmD, medications safety coordinator at the University of Colorado Hospital, says teamwork is the best way to avoid errors. “This would include the pharmacist who would determine appropriate in-house drug therapy, whether that would be determining dosage or specific drugs for specific patients’ needs. It would include making sure they’re providing sufficient information to the nurse at the bedside,” Dr. May says. “I think one of the biggest contributing factors to medication errors is poor communication.”

Dr. Sachdeva agrees direct communication is vital.

“I think hospitalists are in a unique position because we interact with almost everyone who cares for the patient,” Dr. Sachdeva says. “When I’m working, I’m talking continuously with the nurses. I think it’s important to have an open dialogue. I’ve learned that if I make a change, whether it’s on paper or on the computer, if I talk to the nurse, there is more chance it will happen earlier and it will happen correctly.”

When Errors Occur

Early detection of errors is imperative. “You want to make sure patient monitoring is frequent and specialized to the drugs they’re receiving,” Dr. May says.

If an overdose occurs before an error is detected, it’s important to strategize the treatment based on the error in question. Treatment depends on how much drug the patient received and what specific drug was given in error, Dr. May explains.

“Many hospitals have a rapid response team that will go to the bedside of patients who are showing signs of acute change in their condition, including overdoses,” Dr. Bossard says. ”The response team will assess that patient immediately and then contact the primary care physician or the hospitalist to address those issues. On the process management side, each sentinel event is reviewed in exceedingly fine detail, so processes can be adjusted and made safer in the future.”

In fact, more hospitals are creating an environment where it’s OK to admit that you’ve made a mistake. “We need to move away from blame and realize that these are patient safety issues about which we all need to be honest,” Dr. Basco says. “Part of that means full disclosure to the patient once you detect that an error has occurred. There’s no benefit to you or from a medical-legal standpoint of trying to keep it hush-hush. In fact, there’s a lot of evidence that disclosing [the error] early is beneficial.”

The Usual Suspects

A few classes of drugs are considered especially risky, Dr. May says, including narcotics, anticoagulants and insulin. These drugs aren’t necessarily involved in medication errors at a higher frequency, but they receive a lot of attention because, when an error does occur with these medications, the outcome tends to be more serious, she says.

Anti-epileptic agents, chemotherapeutic agents, and immuno-suppressants, especially in patients who have undergone transplants, can be risky. “What may be a therapeutic level for one patient may not be for a transplant patient,” Dr. Wright says.

Dr. Ferrance says he finds narcotics to be the riskiest class of drugs, especially in post-operative patients. “The dosing range is so wide to begin with,” he says, “Surgeons are afraid of not treating pain adequately, and they’re afraid of an overdose.”

Last but Not Least

A known-yet-underrepresented problem is medication reconciliation from inpatient to outpatient and vice versa. Studies clearly show that post-discharge telephone calls and home visits identify problems in medication dosing and compliance, according to Dr. Bossard. “Systems really need to be in place to facilitate this level of service, both when the patient comes into the hospital and after they’ve been discharged.” TH

Reference

1. The Journal of the American Medical Association. Medication errors continue even in highly computerized hospital. ScienceDaily. www.sciencedaily.com/releases/2005/05/050524101312.htm Published May 24, 2005. Accessed September 30, 2008.

Last summer, 17 infants mistakenly were given incorrect doses of the blood-thinning medication heparin during their stay at a hospital in Corpus Christi, Texas. Two of those infants died.

Thousands of medication errors, including the ordering, dispensing and monitoring of medication, occur each year in hospitals throughout the country. Several studies in recent years have shown that injuries resulting from adverse drug events (ADEs) account for up to 41 percent of all hospital admissions and more than two billion dollars annually in inpatient costs.

Whether a patient is an infant, child or adult, the potential for medication errors begins as soon as a patient reaches the hospital and continues well after discharge.

“Medication errors often start when the patient comes to the emergency room,” says Sandeep Sachdeva, MD, clinical assistant professor at University of Washington Medical Center in Seattle. “Patients usually don’t carry a detailed list of the drugs they’re taking. If they come in late at night, it may not be possible for us to get an alternative list.”

That’s why it’s important for drug reconciliation to begin at the time of arrival, Dr. Sachdeva says. “In my opinion, medication reconciliation is a dynamic process, and medication reconciliation is a daily process. When patients come into the hospital, certain medications automatically get changed to the medications that are available in hospitals, and anytime there is a change in medications, it’s an opportunity for an error.”

Opportunities for Error

Even if a patient arrives with a full medication list, once he or she transfers from one hospital unit to another or is discharged, the opportunity for errors increases exponentially, says Julia Wright, MD, director of hospital medicine at University of Wisconsin Hospital and associate professor of medicine at The University of Wisconsin School of Medicine and Public Health in Madison, Wis.

“What providers have to remember is that there are multiple stages at which mistakes can be made,” says William Basco, MD, director of general pediatrics at the Medical University of South Carolina in Charleston, S.C. The physician or nurse practitioner can make a mistake writing the order; a nurse can misread the order; a pharmacist can incorrectly prepare the order; and a floor nurse can make a mistake drawing up the medication or delivering it, Dr Basco explains.

What’s a Hospitalist To Do?

Although the opportunities for medication errors are many, Dr. Basco says hospitalists should take several steps to mitigate medication errors. First, he says, limit verbal orders for drugs. Instead, write the order out, print legibly and refrain from using abbreviations. He suggests writing out numbers and placing them inside parentheses after the corresponding numeral.

“It’s important to write out medications that could be confused with the abbreviations of another medication, and avoid shorthand notations that can be confused with a number when it’s actually a letter,” Dr. Wright says.

Second, avoid trailing zeros. “If you want to give 10 ml of something, write it as 10 and spell out ml, not 10.0,” Dr. Basco says. “Don’t use unnecessary decimal places, especially when the order is faxed. A 10.0 could be read as 100 if the decimal point doesn’t come across clearly. That’s how you get a 10-fold dosing error.”

Additionally, the patient’s weight should be checked carefully and rechecked, especially when ordering riskier drugs, such as anti-coagulants and narcotics. “Our hospital pharmacy requires a weight on every drug order, so they can do calculations on whether the dose is appropriate,” Dr. Basco says. “They are requiring us to write down the drug that we want to deliver and its dose, as well as the milligram per kilogram per dose we want to deliver, so they can double check whether we’ve done our dosage calculation properly.”

Computers to the Rescue

More and more hospitals are moving toward electronic recordkeeping, including computerized physician order entry, also known as CPOE. “Although electronic records won’t eliminate errors, they tend to reduce them, especially when they include decision support,” Dr. Sachdeva says. “Decision support means that this is a ‘smart’ program that can look at the dose you ordered and tell you if the dose is correct based on the patient’s weight. It also scans the other medications that the person is on and make sure there are no allergies or potential drug interactions. Or, it can even disallow you ordering drugs that it knows will interact or know will cause allergies. The system won’t let you.”

For those hospitalists still required to write out orders, Randy Ferrance, DC, MD, a dual boarded internal medicine and pediatrics hospitalist at Riverside Tappahannock Hospital in Tappahannock, Va., says multiple checks and balances, from the time the drug is ordered to the time the patient receives the drug, are essential for reducing errors. “We write the order for the expected dosage per kilo and then the charge nurse checks our math, and then the pharmacist checks not only the math, but the expected dosage for the patient,” Dr. Ferrance says. Understanding the proper dosing range for specific drugs, he adds, is as crucial as is taking into account renal function.

Check with the Pharmacist

More hospitals are including pharmacists in their multi-disciplinary rounds, says Brian Bossard, MD, founder and director of Inpatient Physician Associates in Lincoln, Neb.

“We have a single pharmacist who works with each of our teams and functions as a liaison with the rest of the pharmacist staff in the hospital,” Dr. Bossard says. “This pharmacist reviews the medication list of each of our patients and focuses on patient safety initiatives, drug interactions and cost. The pharmacist writes up the verbal order after he talks to us, so there is no delay in getting the order on the chart. That, I think, goes a long way, in preventing drug-drug interactions that can lead to problems. Really, every day there are circumstances that are identified by the pharmacist that we change, so every day we’re seeing the benefits of this relationship.”

Dr. Bossard says his group has a second pharmacist who provides requested educational information on a day-to-day basis, in terms of article and literature reviews. “It’s a great relationship,” he says. “They love to do that, and we love the information that they get for us.”

Work as a Team

Sondra May, PharmD, medications safety coordinator at the University of Colorado Hospital, says teamwork is the best way to avoid errors. “This would include the pharmacist who would determine appropriate in-house drug therapy, whether that would be determining dosage or specific drugs for specific patients’ needs. It would include making sure they’re providing sufficient information to the nurse at the bedside,” Dr. May says. “I think one of the biggest contributing factors to medication errors is poor communication.”

Dr. Sachdeva agrees direct communication is vital.

“I think hospitalists are in a unique position because we interact with almost everyone who cares for the patient,” Dr. Sachdeva says. “When I’m working, I’m talking continuously with the nurses. I think it’s important to have an open dialogue. I’ve learned that if I make a change, whether it’s on paper or on the computer, if I talk to the nurse, there is more chance it will happen earlier and it will happen correctly.”

When Errors Occur

Early detection of errors is imperative. “You want to make sure patient monitoring is frequent and specialized to the drugs they’re receiving,” Dr. May says.

If an overdose occurs before an error is detected, it’s important to strategize the treatment based on the error in question. Treatment depends on how much drug the patient received and what specific drug was given in error, Dr. May explains.

“Many hospitals have a rapid response team that will go to the bedside of patients who are showing signs of acute change in their condition, including overdoses,” Dr. Bossard says. ”The response team will assess that patient immediately and then contact the primary care physician or the hospitalist to address those issues. On the process management side, each sentinel event is reviewed in exceedingly fine detail, so processes can be adjusted and made safer in the future.”

In fact, more hospitals are creating an environment where it’s OK to admit that you’ve made a mistake. “We need to move away from blame and realize that these are patient safety issues about which we all need to be honest,” Dr. Basco says. “Part of that means full disclosure to the patient once you detect that an error has occurred. There’s no benefit to you or from a medical-legal standpoint of trying to keep it hush-hush. In fact, there’s a lot of evidence that disclosing [the error] early is beneficial.”

The Usual Suspects

A few classes of drugs are considered especially risky, Dr. May says, including narcotics, anticoagulants and insulin. These drugs aren’t necessarily involved in medication errors at a higher frequency, but they receive a lot of attention because, when an error does occur with these medications, the outcome tends to be more serious, she says.

Anti-epileptic agents, chemotherapeutic agents, and immuno-suppressants, especially in patients who have undergone transplants, can be risky. “What may be a therapeutic level for one patient may not be for a transplant patient,” Dr. Wright says.

Dr. Ferrance says he finds narcotics to be the riskiest class of drugs, especially in post-operative patients. “The dosing range is so wide to begin with,” he says, “Surgeons are afraid of not treating pain adequately, and they’re afraid of an overdose.”

Last but Not Least

A known-yet-underrepresented problem is medication reconciliation from inpatient to outpatient and vice versa. Studies clearly show that post-discharge telephone calls and home visits identify problems in medication dosing and compliance, according to Dr. Bossard. “Systems really need to be in place to facilitate this level of service, both when the patient comes into the hospital and after they’ve been discharged.” TH

Reference

1. The Journal of the American Medical Association. Medication errors continue even in highly computerized hospital. ScienceDaily. www.sciencedaily.com/releases/2005/05/050524101312.htm Published May 24, 2005. Accessed September 30, 2008.

Little information is available on how teaching outcomes involving academic hospitalists and resident physicians affect patient safety and error rates—particularly under duty-hour restrictions on residents by the Accreditation Council for Graduate Medical Education (ACGME).

But data show that when medical errors occur they are often connected with residents’ errors in judgment, lack of technical competence, inadequate supervision by senior physicians, and a breakdown in teamwork.1 In a study of 889 cases resulting in error and injury, 240 involved trainees with at least a “moderately important” role. Among the findings:

• Residents were involved in 208 of those 240 cases;
• 168 of the cases occurred in the inpatient setting;
• 80 of the cases involved obstetrics-gynecology residents, and 45 involved general surgery residents;
• Trainees “lacked technical competence or knowledge” of diagnosis in 67 cases; and
• Attending physicians were involved in 106 supervision failures.

Based on this information, how can academic hospitalists best supervise residents to reduce errors and optimize patient safety and treatment while enhancing residents’ training and satisfaction? Academic hospitalists across the United States grapple with this question daily. And a few have come up with ways that meet the needs of patients and residents.

Oversight vs. Hindsight

Reflecting on his residency, Eric Siegal, MD, a regional medical director with Cogent Healthcare in Madison, Wis., and chair of SHM’s Public Policy Committee, says he recalls times when he did not receive sufficient oversight from senior physicians. Consequently, he and his patients suffered, he says.

“We were thrown into things with little or no supervision, and we were told to sink or swim,” he says. “The good news is that we learned a ton on our own. The bad news is we hurt people in the process. So, the question is how do you walk a line of creating house staff who are autonomous and competent while protecting the patient?”

As an attending physician at the University of Wisconsin, Dr. Siegal says he gave his residents autonomy to make decisions. But there were things he did not let them do alone or without first asking. “The obvious thing was procedures,” he notes. “When residents did procedures, I was standing right there next to them. The extent to which I got involved was entirely dependent on the extent to which the resident was competent.”

Likewise, Alpesh Amin, MD, MBA, professor and chief, division of general internal medicine and executive director of the hospitalist program at the University of California, Irvine, says he gives residents oversight but doesn’t hover. “Otherwise they’re not learning from experience by only doing what someone else tells them to do,” he says. “But without oversight, you don’t prevent errors.”

Dr. Amin, a member of SHM’s Board of Directors, says that as an attending he begins the month with an orientation, reviewing items that help prevent hospital errors. For example, he urges residents before giving medicine to think about possible renal insufficiency and drug interactions. He says he also stresses the importance of preventive techniques.

Developing a system that allows residents to feel comfortable approaching their attending with questions is also vital, says Dr. Amin. Meanwhile, the attending needs to feel he can ask residents pointed questions, yet allow them to think things through.

Dr. Siegal maintained a dialogue with residents regarding the degree of supervision they needed. “A week into the rotation, I asked them how they felt,” he recalls. “Are you getting enough supervision? Too much? Most residents have a reasonable sense of what their deficiencies and discomforts are.”

Joseph Li, MD, director of the hospital medicine program at Boston’s Beth Israel Deaconess Medical Center and assistant professor of medicine at Harvard Medical School, and Kenneth Epstein, MD, MBA, a hospitalist and director of medical affairs and clinical research at IPC-The Hospitalist Company, agree. Dr. Li, also an SHM board member, says not only are residents seeking the right amount of supervision, they’re also seeking the right type of supervision based on their strengths and weaknesses. He says residents also are looking for something else—a medical model. “I think they look for someone to model themselves after,” he suggests. “I think all of us do throughout life, sometimes on purpose but also without intending to do so to better ourselves and learn how to do things.”

Culture Change

Once an atmosphere rife with assigning blame for medical errors, teaching hospitals are changing how errors are found and disclosed, says Michael Lukela, MD, director of the pediatrics program at the University of Michigan and assistant professor of internal medicine and pediatrics.

“The focus is now on patient safety and looking more broadly at how medical errors come about,” he says. “The focus is shifting away from the individual while not overlooking the personal responsibility. There should be safeguards in place, which should prevent errors from occurring, so errors are not just about one person.

“Trainees want to know about the culture. What if they do make an error? Who should they talk with? Their attending? Many are fearful, but these fears don’t have basis. It’s based on what they experience in medical school, saw on TV, and learned from observing others.”

Instead, Dr. Lukela says residents should be saying: “ ‘I don’t understand how my patient got this wrong medication. How can we prevent that?’ It’s up to us as educators to step back and say, ‘That’s a great question’ and get them to think about why errors happen.”

Residents want to focus on the big picture—to learn the art of practicing medicine and get support to do what they need to do, says Dr. Amin. And attendings are looking for residents motivated to learn. “It takes time, energy, and motivation to teach—just like it takes time, energy, and motivation to take care of patients,” he says. “And the hospitalist is in the perfect position to do that.”

Hand-Off Errors

Although hand-offs long have been a part of hospital medicine, the ACGME’s recent resident work-hour limit has raised questions concerning its benefits and drawbacks.

“The concept of 80 hours [a week] is a very good one, but practically it has meant increasing the number of hand-offs,” says Dr. Lukela. “And when you’re increasing the number of handoffs, there’s an increased potential in increasing errors.”

To prevent errors, Dr. Amin says it’s essential to develop a culture around proper hand-offs. “Taking care of patients is not just about getting a history and giving patients drugs or doing surgery,” he cautions. “It’s also thinking about potential errors that can occur and minimizing them through the process of care.”

Dr. Lukela agrees, saying the key part of the hand-off that affects efficiency, quality of care, and error reduction is the thought process of the physician handing off. What is the patient’s history? What tests are pending? What is the action plan? And from day one in the hospital, he says, there needs to be a discharge plan so residents know what direction the patient is going in.

Residents also need to learn that information needs to be meticulously transmitted when there is a transition of care from hospital to nursing facility or from hospital to home. “Residents may view life in the academic center as a vacuum from the outside primary care world,” says Dr. Epstein. “The residents may see the care as what they did in the hospital, but the care is part of a continuum from the primary care, the person’s doctor,” he says.

Team Approach

For hospitalist Julia Wright, MD, associate clinical professor of medicine and director of hospital medicine at the University of Wisconsin School of Medicine and Public Health in Madison, teamwork coupled with redundancy has proven an effective method of teaching residents while delivering first-rate patient care.

“I structure the learning environment so that each person knows what level of responsibility he has within the healthcare team,” she says.

Dr. Wright requires that medical students learn how wards work, that interns learn more about diagnosis and management, and that residents learn how to assign responsibility to the patient team while taking responsibility for patient care. Meanwhile, the attending makes sure the proper diagnosis has been made, and the treatment plan has been carried out.

This arrangement she finds helps her teach and helps prevent errors. “What happens is that there’s some duplication of effort within the medical team,” says Dr. Wright. “But you want more than one person checking to make sure things are getting done, and that way it’s not only excellent care for the patient, but it’s a learning environment.”

The Bottom Line

Dr. Wright says she favors training residents by teaching them about each patient being cared for and that patient’s particular manifestation of a disease. “This method fits in very well with the whole idea of how each one of us is working to help this patient with this condition. I like to pool information and actually take care of the patient as we talk about a condition: helping that patient improve, helping make the diagnosis, helping decide on a treatment. The bottom line is the patient, getting the patient excellent care,” says Dr. Wright.

“As teachers, we try to teach with emotions,” says Dr. Li. “When we teach trainees to care for patients we try to think about how to make it memorable for them—and you remember something that’s emotional,” “So, despite some of the challenges we face, I think we’re at a better place than we were 10 years ago, having hospitalists on the wards. And I think 10 years from now, we’re going to be in an even better place. We’ll have the luxury of 10 more years of clinical experience and emotional experience to impart to trainees.” TH

Robin Tricoles is a medical writer based in New Jersey.

Reference

1. Singh H, Thomas EJ, Peterson LA, et al. Medical errors involving trainees. A study of closed malpractice claims from 5 insurers. Arch Intern Med. 2007 Oct;167(19):2030-2036.

Little information is available on how teaching outcomes involving academic hospitalists and resident physicians affect patient safety and error rates—particularly under duty-hour restrictions on residents by the Accreditation Council for Graduate Medical Education (ACGME).

But data show that when medical errors occur they are often connected with residents’ errors in judgment, lack of technical competence, inadequate supervision by senior physicians, and a breakdown in teamwork.1 In a study of 889 cases resulting in error and injury, 240 involved trainees with at least a “moderately important” role. Among the findings:

• Residents were involved in 208 of those 240 cases;
• 168 of the cases occurred in the inpatient setting;
• 80 of the cases involved obstetrics-gynecology residents, and 45 involved general surgery residents;
• Trainees “lacked technical competence or knowledge” of diagnosis in 67 cases; and
• Attending physicians were involved in 106 supervision failures.

Based on this information, how can academic hospitalists best supervise residents to reduce errors and optimize patient safety and treatment while enhancing residents’ training and satisfaction? Academic hospitalists across the United States grapple with this question daily. And a few have come up with ways that meet the needs of patients and residents.

Oversight vs. Hindsight

Reflecting on his residency, Eric Siegal, MD, a regional medical director with Cogent Healthcare in Madison, Wis., and chair of SHM’s Public Policy Committee, says he recalls times when he did not receive sufficient oversight from senior physicians. Consequently, he and his patients suffered, he says.

“We were thrown into things with little or no supervision, and we were told to sink or swim,” he says. “The good news is that we learned a ton on our own. The bad news is we hurt people in the process. So, the question is how do you walk a line of creating house staff who are autonomous and competent while protecting the patient?”

As an attending physician at the University of Wisconsin, Dr. Siegal says he gave his residents autonomy to make decisions. But there were things he did not let them do alone or without first asking. “The obvious thing was procedures,” he notes. “When residents did procedures, I was standing right there next to them. The extent to which I got involved was entirely dependent on the extent to which the resident was competent.”

Likewise, Alpesh Amin, MD, MBA, professor and chief, division of general internal medicine and executive director of the hospitalist program at the University of California, Irvine, says he gives residents oversight but doesn’t hover. “Otherwise they’re not learning from experience by only doing what someone else tells them to do,” he says. “But without oversight, you don’t prevent errors.”

Dr. Amin, a member of SHM’s Board of Directors, says that as an attending he begins the month with an orientation, reviewing items that help prevent hospital errors. For example, he urges residents before giving medicine to think about possible renal insufficiency and drug interactions. He says he also stresses the importance of preventive techniques.

Developing a system that allows residents to feel comfortable approaching their attending with questions is also vital, says Dr. Amin. Meanwhile, the attending needs to feel he can ask residents pointed questions, yet allow them to think things through.

Dr. Siegal maintained a dialogue with residents regarding the degree of supervision they needed. “A week into the rotation, I asked them how they felt,” he recalls. “Are you getting enough supervision? Too much? Most residents have a reasonable sense of what their deficiencies and discomforts are.”

Joseph Li, MD, director of the hospital medicine program at Boston’s Beth Israel Deaconess Medical Center and assistant professor of medicine at Harvard Medical School, and Kenneth Epstein, MD, MBA, a hospitalist and director of medical affairs and clinical research at IPC-The Hospitalist Company, agree. Dr. Li, also an SHM board member, says not only are residents seeking the right amount of supervision, they’re also seeking the right type of supervision based on their strengths and weaknesses. He says residents also are looking for something else—a medical model. “I think they look for someone to model themselves after,” he suggests. “I think all of us do throughout life, sometimes on purpose but also without intending to do so to better ourselves and learn how to do things.”

Culture Change

Once an atmosphere rife with assigning blame for medical errors, teaching hospitals are changing how errors are found and disclosed, says Michael Lukela, MD, director of the pediatrics program at the University of Michigan and assistant professor of internal medicine and pediatrics.

“The focus is now on patient safety and looking more broadly at how medical errors come about,” he says. “The focus is shifting away from the individual while not overlooking the personal responsibility. There should be safeguards in place, which should prevent errors from occurring, so errors are not just about one person.

“Trainees want to know about the culture. What if they do make an error? Who should they talk with? Their attending? Many are fearful, but these fears don’t have basis. It’s based on what they experience in medical school, saw on TV, and learned from observing others.”

Instead, Dr. Lukela says residents should be saying: “ ‘I don’t understand how my patient got this wrong medication. How can we prevent that?’ It’s up to us as educators to step back and say, ‘That’s a great question’ and get them to think about why errors happen.”

Residents want to focus on the big picture—to learn the art of practicing medicine and get support to do what they need to do, says Dr. Amin. And attendings are looking for residents motivated to learn. “It takes time, energy, and motivation to teach—just like it takes time, energy, and motivation to take care of patients,” he says. “And the hospitalist is in the perfect position to do that.”

Hand-Off Errors

Although hand-offs long have been a part of hospital medicine, the ACGME’s recent resident work-hour limit has raised questions concerning its benefits and drawbacks.

“The concept of 80 hours [a week] is a very good one, but practically it has meant increasing the number of hand-offs,” says Dr. Lukela. “And when you’re increasing the number of handoffs, there’s an increased potential in increasing errors.”

To prevent errors, Dr. Amin says it’s essential to develop a culture around proper hand-offs. “Taking care of patients is not just about getting a history and giving patients drugs or doing surgery,” he cautions. “It’s also thinking about potential errors that can occur and minimizing them through the process of care.”

Dr. Lukela agrees, saying the key part of the hand-off that affects efficiency, quality of care, and error reduction is the thought process of the physician handing off. What is the patient’s history? What tests are pending? What is the action plan? And from day one in the hospital, he says, there needs to be a discharge plan so residents know what direction the patient is going in.

Residents also need to learn that information needs to be meticulously transmitted when there is a transition of care from hospital to nursing facility or from hospital to home. “Residents may view life in the academic center as a vacuum from the outside primary care world,” says Dr. Epstein. “The residents may see the care as what they did in the hospital, but the care is part of a continuum from the primary care, the person’s doctor,” he says.

Team Approach

For hospitalist Julia Wright, MD, associate clinical professor of medicine and director of hospital medicine at the University of Wisconsin School of Medicine and Public Health in Madison, teamwork coupled with redundancy has proven an effective method of teaching residents while delivering first-rate patient care.

“I structure the learning environment so that each person knows what level of responsibility he has within the healthcare team,” she says.

Dr. Wright requires that medical students learn how wards work, that interns learn more about diagnosis and management, and that residents learn how to assign responsibility to the patient team while taking responsibility for patient care. Meanwhile, the attending makes sure the proper diagnosis has been made, and the treatment plan has been carried out.

This arrangement she finds helps her teach and helps prevent errors. “What happens is that there’s some duplication of effort within the medical team,” says Dr. Wright. “But you want more than one person checking to make sure things are getting done, and that way it’s not only excellent care for the patient, but it’s a learning environment.”

The Bottom Line

Dr. Wright says she favors training residents by teaching them about each patient being cared for and that patient’s particular manifestation of a disease. “This method fits in very well with the whole idea of how each one of us is working to help this patient with this condition. I like to pool information and actually take care of the patient as we talk about a condition: helping that patient improve, helping make the diagnosis, helping decide on a treatment. The bottom line is the patient, getting the patient excellent care,” says Dr. Wright.

“As teachers, we try to teach with emotions,” says Dr. Li. “When we teach trainees to care for patients we try to think about how to make it memorable for them—and you remember something that’s emotional,” “So, despite some of the challenges we face, I think we’re at a better place than we were 10 years ago, having hospitalists on the wards. And I think 10 years from now, we’re going to be in an even better place. We’ll have the luxury of 10 more years of clinical experience and emotional experience to impart to trainees.” TH

Robin Tricoles is a medical writer based in New Jersey.

Reference

1. Singh H, Thomas EJ, Peterson LA, et al. Medical errors involving trainees. A study of closed malpractice claims from 5 insurers. Arch Intern Med. 2007 Oct;167(19):2030-2036.

Little information is available on how teaching outcomes involving academic hospitalists and resident physicians affect patient safety and error rates—particularly under duty-hour restrictions on residents by the Accreditation Council for Graduate Medical Education (ACGME).

But data show that when medical errors occur they are often connected with residents’ errors in judgment, lack of technical competence, inadequate supervision by senior physicians, and a breakdown in teamwork.1 In a study of 889 cases resulting in error and injury, 240 involved trainees with at least a “moderately important” role. Among the findings:

• Residents were involved in 208 of those 240 cases;
• 168 of the cases occurred in the inpatient setting;
• 80 of the cases involved obstetrics-gynecology residents, and 45 involved general surgery residents;
• Trainees “lacked technical competence or knowledge” of diagnosis in 67 cases; and
• Attending physicians were involved in 106 supervision failures.

Based on this information, how can academic hospitalists best supervise residents to reduce errors and optimize patient safety and treatment while enhancing residents’ training and satisfaction? Academic hospitalists across the United States grapple with this question daily. And a few have come up with ways that meet the needs of patients and residents.

Oversight vs. Hindsight

Reflecting on his residency, Eric Siegal, MD, a regional medical director with Cogent Healthcare in Madison, Wis., and chair of SHM’s Public Policy Committee, says he recalls times when he did not receive sufficient oversight from senior physicians. Consequently, he and his patients suffered, he says.

“We were thrown into things with little or no supervision, and we were told to sink or swim,” he says. “The good news is that we learned a ton on our own. The bad news is we hurt people in the process. So, the question is how do you walk a line of creating house staff who are autonomous and competent while protecting the patient?”

As an attending physician at the University of Wisconsin, Dr. Siegal says he gave his residents autonomy to make decisions. But there were things he did not let them do alone or without first asking. “The obvious thing was procedures,” he notes. “When residents did procedures, I was standing right there next to them. The extent to which I got involved was entirely dependent on the extent to which the resident was competent.”

Likewise, Alpesh Amin, MD, MBA, professor and chief, division of general internal medicine and executive director of the hospitalist program at the University of California, Irvine, says he gives residents oversight but doesn’t hover. “Otherwise they’re not learning from experience by only doing what someone else tells them to do,” he says. “But without oversight, you don’t prevent errors.”

Dr. Amin, a member of SHM’s Board of Directors, says that as an attending he begins the month with an orientation, reviewing items that help prevent hospital errors. For example, he urges residents before giving medicine to think about possible renal insufficiency and drug interactions. He says he also stresses the importance of preventive techniques.

Developing a system that allows residents to feel comfortable approaching their attending with questions is also vital, says Dr. Amin. Meanwhile, the attending needs to feel he can ask residents pointed questions, yet allow them to think things through.

Dr. Siegal maintained a dialogue with residents regarding the degree of supervision they needed. “A week into the rotation, I asked them how they felt,” he recalls. “Are you getting enough supervision? Too much? Most residents have a reasonable sense of what their deficiencies and discomforts are.”

Joseph Li, MD, director of the hospital medicine program at Boston’s Beth Israel Deaconess Medical Center and assistant professor of medicine at Harvard Medical School, and Kenneth Epstein, MD, MBA, a hospitalist and director of medical affairs and clinical research at IPC-The Hospitalist Company, agree. Dr. Li, also an SHM board member, says not only are residents seeking the right amount of supervision, they’re also seeking the right type of supervision based on their strengths and weaknesses. He says residents also are looking for something else—a medical model. “I think they look for someone to model themselves after,” he suggests. “I think all of us do throughout life, sometimes on purpose but also without intending to do so to better ourselves and learn how to do things.”

Culture Change

Once an atmosphere rife with assigning blame for medical errors, teaching hospitals are changing how errors are found and disclosed, says Michael Lukela, MD, director of the pediatrics program at the University of Michigan and assistant professor of internal medicine and pediatrics.

“The focus is now on patient safety and looking more broadly at how medical errors come about,” he says. “The focus is shifting away from the individual while not overlooking the personal responsibility. There should be safeguards in place, which should prevent errors from occurring, so errors are not just about one person.

“Trainees want to know about the culture. What if they do make an error? Who should they talk with? Their attending? Many are fearful, but these fears don’t have basis. It’s based on what they experience in medical school, saw on TV, and learned from observing others.”

Instead, Dr. Lukela says residents should be saying: “ ‘I don’t understand how my patient got this wrong medication. How can we prevent that?’ It’s up to us as educators to step back and say, ‘That’s a great question’ and get them to think about why errors happen.”

Residents want to focus on the big picture—to learn the art of practicing medicine and get support to do what they need to do, says Dr. Amin. And attendings are looking for residents motivated to learn. “It takes time, energy, and motivation to teach—just like it takes time, energy, and motivation to take care of patients,” he says. “And the hospitalist is in the perfect position to do that.”

Hand-Off Errors

Although hand-offs long have been a part of hospital medicine, the ACGME’s recent resident work-hour limit has raised questions concerning its benefits and drawbacks.

“The concept of 80 hours [a week] is a very good one, but practically it has meant increasing the number of hand-offs,” says Dr. Lukela. “And when you’re increasing the number of handoffs, there’s an increased potential in increasing errors.”

To prevent errors, Dr. Amin says it’s essential to develop a culture around proper hand-offs. “Taking care of patients is not just about getting a history and giving patients drugs or doing surgery,” he cautions. “It’s also thinking about potential errors that can occur and minimizing them through the process of care.”

Dr. Lukela agrees, saying the key part of the hand-off that affects efficiency, quality of care, and error reduction is the thought process of the physician handing off. What is the patient’s history? What tests are pending? What is the action plan? And from day one in the hospital, he says, there needs to be a discharge plan so residents know what direction the patient is going in.

Residents also need to learn that information needs to be meticulously transmitted when there is a transition of care from hospital to nursing facility or from hospital to home. “Residents may view life in the academic center as a vacuum from the outside primary care world,” says Dr. Epstein. “The residents may see the care as what they did in the hospital, but the care is part of a continuum from the primary care, the person’s doctor,” he says.

Team Approach

For hospitalist Julia Wright, MD, associate clinical professor of medicine and director of hospital medicine at the University of Wisconsin School of Medicine and Public Health in Madison, teamwork coupled with redundancy has proven an effective method of teaching residents while delivering first-rate patient care.

“I structure the learning environment so that each person knows what level of responsibility he has within the healthcare team,” she says.

Dr. Wright requires that medical students learn how wards work, that interns learn more about diagnosis and management, and that residents learn how to assign responsibility to the patient team while taking responsibility for patient care. Meanwhile, the attending makes sure the proper diagnosis has been made, and the treatment plan has been carried out.

This arrangement she finds helps her teach and helps prevent errors. “What happens is that there’s some duplication of effort within the medical team,” says Dr. Wright. “But you want more than one person checking to make sure things are getting done, and that way it’s not only excellent care for the patient, but it’s a learning environment.”

The Bottom Line

Dr. Wright says she favors training residents by teaching them about each patient being cared for and that patient’s particular manifestation of a disease. “This method fits in very well with the whole idea of how each one of us is working to help this patient with this condition. I like to pool information and actually take care of the patient as we talk about a condition: helping that patient improve, helping make the diagnosis, helping decide on a treatment. The bottom line is the patient, getting the patient excellent care,” says Dr. Wright.

“As teachers, we try to teach with emotions,” says Dr. Li. “When we teach trainees to care for patients we try to think about how to make it memorable for them—and you remember something that’s emotional,” “So, despite some of the challenges we face, I think we’re at a better place than we were 10 years ago, having hospitalists on the wards. And I think 10 years from now, we’re going to be in an even better place. We’ll have the luxury of 10 more years of clinical experience and emotional experience to impart to trainees.” TH

Robin Tricoles is a medical writer based in New Jersey.

Reference

1. Singh H, Thomas EJ, Peterson LA, et al. Medical errors involving trainees. A study of closed malpractice claims from 5 insurers. Arch Intern Med. 2007 Oct;167(19):2030-2036.

In January 2005, the Institute for Healthcare Improvement (IHI) launched an ambitious campaign aimed at preventing unnecessary patient deaths and improving U.S. healthcare. Since then, IHI estimates that more than 122,300 lives have been saved.

Known as the “100,000 Lives Campaign,” the movement encourages hospitals to use evidence-based clinical interventions with the goal of preventing 100,000 avoidable deaths by June 2006. These interventions focus on six areas, one that includes the prevention of ventilator-associated pneumonia (VAP).

According to the IHI Web site, VAP occurs in up to 15% of patients receiving mechanical ventilation, making it a relatively common problem. Although data vary on how many fatalities result directly from VAP, it is widely agreed that those patients who are the sickest and using mechanical ventilators the longest run the greatest risk of dying from VAP or its related complications.

“If someone is on the ventilator one day, their risk is relatively low, but for each additional day they’re on the ventilator there’s a small increasing percentage that they will develop pneumonia,” says Greg Martin, MD, a pulmonary and critical care specialist at Atlanta’s Grady Memorial and Crawford Long hospitals. For the sickest patients who are on the respirator longest (for days or even weeks), the risk can add up quickly and become “quite substantial,” says Dr. Martin.

This risk is why IHI has encouraged hospitals to use what is known as a “ventilator bundle” to reduce the incidence of VAP in all mechanically ventilated patients unless the bundle is contraindicated. The ventilator bundle includes four components. The first two seek to prevent VAP, and the latter two seek to prevent VAP-related complications through prophylaxis of peptic ulcer disease (PUD) and deep vein thrombosis (DVT), unless contraindicated.

The first preventative component calls for elevating the head of the patient’s bed to 30 to 45 degrees, thereby reducing aspiration of gastric secretions. “If you look at all the interventions, it’s probably the most effective and simplest of them all—and costs nearly nothing,” says Dr. Martin.

Not quite as simple but proven effective, the IHI’s second component calls for sedation vacations; that is, interrupting or reducing the amount of sedation patients receive each day so they can be evaluated daily for extubation. Dr. Martin says studies show that sedation vacations allow many patients to come off the respirator more quickly and spend less time in the ICU, thereby saving money, time, and lives.

Vicki Spuhler, nurse manager of the respiratory ICU at Latter Day Saints Hospital, part of Intermountain Healthcare in Salt Lake City, says, “When the bundle is consistently applied, we consistently see a significant drop in VAP. Each element is important. But it’s the bundling and consistent, reliable application of the elements that make it effective.”

Joe McCannon, “100,000 Lives Campaign” manager, says several of the more than 3,100 participating hospitals have gone six months (some a year) with no reports of VAP.

“What that kind of result says to hospitals around the country is there are no more excuses,” explains McCannon. “You can’t say because of the type of facility we are, because of the type of resources we have, we can’t make this change.”

If using the ventilator bundle is proving effective, why is the bundle not used more often? “People don’t do it (use the bundle) for whole host of reasons,” says John P. Kress, MD, director of pulmonary and critical care procedure service at the University of Chicago’s Department of Medicine. “Those reasons run the spectrum from lack of awareness of the literature to skepticism about the quality of the studies to skepticism about the widespread applicability.”

Yet, these healthcare providers may want to carefully consider why they’re not using the ventilator bundle—or at least parts of it, he says. Sometimes hospitals aren’t in the position to apply all of the components; they’re not practical. But if that’s the case, institutions or individuals who claim there are difficulties may very well want to look long and hard at those problems. “They should think about ways to change the landscape so they can apply these things,” says Dr. Kress. “We need to take the evidence we have and apply it in a careful, thoughtful way to individual patients, and see what happens, and then respond in a careful way. You can’t blindly follow a protocol. You have to modify the individual protocol depending on the circumstances. A protocol is not a mindless cookbook. It’s a starting point, a launch pad.” TH

Robin Tricoles is managing editor of the Journal of Hospital Medicine.

In January 2005, the Institute for Healthcare Improvement (IHI) launched an ambitious campaign aimed at preventing unnecessary patient deaths and improving U.S. healthcare. Since then, IHI estimates that more than 122,300 lives have been saved.

Known as the “100,000 Lives Campaign,” the movement encourages hospitals to use evidence-based clinical interventions with the goal of preventing 100,000 avoidable deaths by June 2006. These interventions focus on six areas, one that includes the prevention of ventilator-associated pneumonia (VAP).

According to the IHI Web site, VAP occurs in up to 15% of patients receiving mechanical ventilation, making it a relatively common problem. Although data vary on how many fatalities result directly from VAP, it is widely agreed that those patients who are the sickest and using mechanical ventilators the longest run the greatest risk of dying from VAP or its related complications.

“If someone is on the ventilator one day, their risk is relatively low, but for each additional day they’re on the ventilator there’s a small increasing percentage that they will develop pneumonia,” says Greg Martin, MD, a pulmonary and critical care specialist at Atlanta’s Grady Memorial and Crawford Long hospitals. For the sickest patients who are on the respirator longest (for days or even weeks), the risk can add up quickly and become “quite substantial,” says Dr. Martin.

This risk is why IHI has encouraged hospitals to use what is known as a “ventilator bundle” to reduce the incidence of VAP in all mechanically ventilated patients unless the bundle is contraindicated. The ventilator bundle includes four components. The first two seek to prevent VAP, and the latter two seek to prevent VAP-related complications through prophylaxis of peptic ulcer disease (PUD) and deep vein thrombosis (DVT), unless contraindicated.

The first preventative component calls for elevating the head of the patient’s bed to 30 to 45 degrees, thereby reducing aspiration of gastric secretions. “If you look at all the interventions, it’s probably the most effective and simplest of them all—and costs nearly nothing,” says Dr. Martin.

Not quite as simple but proven effective, the IHI’s second component calls for sedation vacations; that is, interrupting or reducing the amount of sedation patients receive each day so they can be evaluated daily for extubation. Dr. Martin says studies show that sedation vacations allow many patients to come off the respirator more quickly and spend less time in the ICU, thereby saving money, time, and lives.

Vicki Spuhler, nurse manager of the respiratory ICU at Latter Day Saints Hospital, part of Intermountain Healthcare in Salt Lake City, says, “When the bundle is consistently applied, we consistently see a significant drop in VAP. Each element is important. But it’s the bundling and consistent, reliable application of the elements that make it effective.”

Joe McCannon, “100,000 Lives Campaign” manager, says several of the more than 3,100 participating hospitals have gone six months (some a year) with no reports of VAP.

“What that kind of result says to hospitals around the country is there are no more excuses,” explains McCannon. “You can’t say because of the type of facility we are, because of the type of resources we have, we can’t make this change.”

If using the ventilator bundle is proving effective, why is the bundle not used more often? “People don’t do it (use the bundle) for whole host of reasons,” says John P. Kress, MD, director of pulmonary and critical care procedure service at the University of Chicago’s Department of Medicine. “Those reasons run the spectrum from lack of awareness of the literature to skepticism about the quality of the studies to skepticism about the widespread applicability.”

Yet, these healthcare providers may want to carefully consider why they’re not using the ventilator bundle—or at least parts of it, he says. Sometimes hospitals aren’t in the position to apply all of the components; they’re not practical. But if that’s the case, institutions or individuals who claim there are difficulties may very well want to look long and hard at those problems. “They should think about ways to change the landscape so they can apply these things,” says Dr. Kress. “We need to take the evidence we have and apply it in a careful, thoughtful way to individual patients, and see what happens, and then respond in a careful way. You can’t blindly follow a protocol. You have to modify the individual protocol depending on the circumstances. A protocol is not a mindless cookbook. It’s a starting point, a launch pad.” TH

Robin Tricoles is managing editor of the Journal of Hospital Medicine.

In January 2005, the Institute for Healthcare Improvement (IHI) launched an ambitious campaign aimed at preventing unnecessary patient deaths and improving U.S. healthcare. Since then, IHI estimates that more than 122,300 lives have been saved.

Known as the “100,000 Lives Campaign,” the movement encourages hospitals to use evidence-based clinical interventions with the goal of preventing 100,000 avoidable deaths by June 2006. These interventions focus on six areas, one that includes the prevention of ventilator-associated pneumonia (VAP).

According to the IHI Web site, VAP occurs in up to 15% of patients receiving mechanical ventilation, making it a relatively common problem. Although data vary on how many fatalities result directly from VAP, it is widely agreed that those patients who are the sickest and using mechanical ventilators the longest run the greatest risk of dying from VAP or its related complications.

“If someone is on the ventilator one day, their risk is relatively low, but for each additional day they’re on the ventilator there’s a small increasing percentage that they will develop pneumonia,” says Greg Martin, MD, a pulmonary and critical care specialist at Atlanta’s Grady Memorial and Crawford Long hospitals. For the sickest patients who are on the respirator longest (for days or even weeks), the risk can add up quickly and become “quite substantial,” says Dr. Martin.

This risk is why IHI has encouraged hospitals to use what is known as a “ventilator bundle” to reduce the incidence of VAP in all mechanically ventilated patients unless the bundle is contraindicated. The ventilator bundle includes four components. The first two seek to prevent VAP, and the latter two seek to prevent VAP-related complications through prophylaxis of peptic ulcer disease (PUD) and deep vein thrombosis (DVT), unless contraindicated.

The first preventative component calls for elevating the head of the patient’s bed to 30 to 45 degrees, thereby reducing aspiration of gastric secretions. “If you look at all the interventions, it’s probably the most effective and simplest of them all—and costs nearly nothing,” says Dr. Martin.

Not quite as simple but proven effective, the IHI’s second component calls for sedation vacations; that is, interrupting or reducing the amount of sedation patients receive each day so they can be evaluated daily for extubation. Dr. Martin says studies show that sedation vacations allow many patients to come off the respirator more quickly and spend less time in the ICU, thereby saving money, time, and lives.

Vicki Spuhler, nurse manager of the respiratory ICU at Latter Day Saints Hospital, part of Intermountain Healthcare in Salt Lake City, says, “When the bundle is consistently applied, we consistently see a significant drop in VAP. Each element is important. But it’s the bundling and consistent, reliable application of the elements that make it effective.”

Joe McCannon, “100,000 Lives Campaign” manager, says several of the more than 3,100 participating hospitals have gone six months (some a year) with no reports of VAP.

“What that kind of result says to hospitals around the country is there are no more excuses,” explains McCannon. “You can’t say because of the type of facility we are, because of the type of resources we have, we can’t make this change.”

If using the ventilator bundle is proving effective, why is the bundle not used more often? “People don’t do it (use the bundle) for whole host of reasons,” says John P. Kress, MD, director of pulmonary and critical care procedure service at the University of Chicago’s Department of Medicine. “Those reasons run the spectrum from lack of awareness of the literature to skepticism about the quality of the studies to skepticism about the widespread applicability.”

Yet, these healthcare providers may want to carefully consider why they’re not using the ventilator bundle—or at least parts of it, he says. Sometimes hospitals aren’t in the position to apply all of the components; they’re not practical. But if that’s the case, institutions or individuals who claim there are difficulties may very well want to look long and hard at those problems. “They should think about ways to change the landscape so they can apply these things,” says Dr. Kress. “We need to take the evidence we have and apply it in a careful, thoughtful way to individual patients, and see what happens, and then respond in a careful way. You can’t blindly follow a protocol. You have to modify the individual protocol depending on the circumstances. A protocol is not a mindless cookbook. It’s a starting point, a launch pad.” TH

Robin Tricoles is managing editor of the Journal of Hospital Medicine.