122,300 deaths avoided, report states
By Christopher Doscher, news editor, AAPA News
The 100,000 Lives Campaign, an effort to prevent 100,000 avoidable deaths over 18 months, released its first figures, showing that an estimated 122,300 avoidable deaths have been prevented so far. The campaign was organized by the Institute for Healthcare Improvement (IHI). More than 90 organizations, including AAPA, are partners in the campaign, which has enrolled more than 3,000 hospitals, representing an estimated 75% of hospital beds in the United States.
Participating hospitals are required to implement some or all of the following quality improvement measures: activate a rapid response team to respond at the first sign that a patient's condition is worsening and may lead to a more serious medical emergency; deliver evidence-based care to prevent deaths from MI, such as appropriate administration of aspirin and beta-blockers; ensure accurate and continually updated lists of patients' medications to prevent medication errors; follow steps, such as proper hand washing and cleaning of the patient's skin with antiseptic, to prevent infections in patients receiving central line fluids or medications; follow a series of steps, including timely administration of antibiotics, to prevent infections in patients undergoing surgery; follow four steps, including raising the head of the bed 30 to 45 degrees, to prevent pneumonia in patients on ventilators.
AAPA President Mary Ettari, who attended IHI's announcement at the recent annual meeting of the American Medical Association, said, “This campaign provides a great example of the types of efforts in which PAs can become involved. If hospitals aren't members of the campaign, perhaps PAs can be the instigators to get their hospitals involved in some aspect. Even reducing one unnecessary death in the hospital is positive.” More information about the 100,000 Lives Campaign can be found at www.ihi.org.
AAPA and the Power of Partnering
This POP isn't a family member, but it could still provide you with good advice. The Power of Partnering (POP) Roundtable was established in 2004 by the Alliance Development Team of Novartis Pharmaceuticals to facilitate the exchange of ideas and the discussion of common health care industry issues. The roundtable consists of 29 patient advocacy organizations and professional associations, including AAPA, which is a founding member. The POP initiative has developed a Web site (www.powerofpartnering.com) to facilitate communication among member organizations and the health care community at large. The site contains information on such topics as industry regulations, policy issues, Medicare Part D, and advocacy campaigns. There is information aboutprograms for the uninsured, health disparities, clinical trials, and working with the media. In addition, the coalition holds informal teleconferences and meetings to discuss emerging health care issues and other related topics.
Computer-related errors top self-reported medication incidents
By Christopher Doscher
A review of records of individual medication error events that involved PAs and that were reported by hospitals and clinics showed that the top cause involved the use of a computer, US Pharmacopeia (USP) told AAPA News. The figures were self-reported by hospitals and clinics that hire USP to compile data on medication errors within the institutions, said Rod Hicks, PhD, NP, research coordinator in the USP department of patient safety.
Of the 4,888 incidents, reported between January 1, 2003, and December 31, 2005, 32 were considered harmful, Hicks said, meaning that patients suffered temporary harm, such as discomfort, were hospitalized or permanently harmed, required medical intervention to preserve life, or were killed. The leading cause of errors involved the use of a computer, meaning that the PA used the computer incorrectly or selected the wrong medication through the computer. That happened in 1,747 of the incidents. The second leading cause was performance deficit, meaning that the error could not be attributed to any specific cause. The third leading source of errors was knowledge deficit, meaning that the PA did not know how to order the correct medication, ordered a medication that interacted negatively with another medication the patient was taking, or processed the wrong medication order. Nearly 10% of errors were attributed to the use of abbreviations. The most common type of error was a prescribing error—something was incomplete or inaccurate in the PA's order or prescription. The second most common type, which occurred in about 1,200 cases, was prescribing the wrong dosage of a drug. Omissions also were common, meaning either the PA didn't complete a prescription order or the patient didn't get the proper drug.
Hicks said that the figures are reported by hospitals and clinics so that the organizations can learn what types of errors are occurring and how the errors can be prevented. “Errors can happen to anybody,” he said. “PAs should be willing to report medication errors in the interest of preventing future errors. No PA should ever be fearful. It's a learning opportunity.”