Grant supports patient safety work in rural hospitals

Katherine Jones, Ph.D.

Gary Cochran, Pharm.D.

Keith Mueller, Ph.D.

To ensure the safety of passengers, airline pilots go through a precise system of checks-and-double-checks before each flight. Hospitals need their own rigorous systems to ensure patient safety.

For the past four years, UNMC faculty members — Katherine Jones, Ph.D.; Gary Cochran, Pharm.D.; and Keith Mueller, Ph.D. — have assisted Nebraska’s small rural hospitals in their efforts to prevent medication errors.

Dr. Jones is an assistant professor in UNMC’s Department of Preventive and Societal Medicine, Dr. Cochran is an assistant professor in the UNMC College of Pharmacy and Dr. Mueller is a professor in UNMC’s Preventive and Societal Medicine and the head of the Section on Health Services Research and Rural Health Policy.

Now, their work is being recognized nationally with a grant from the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ). The two-year grant of nearly $600,000 supports the patient safety work that UNMC’s Department of Preventive and Societal Medicine began nearly four years ago related to ordering, preparing, and administering medications in Nebraska’s small rural hospitals. UNMC’s project was one of 15 to receive the AHRQ Partnerships in Implementing Patient Safety grant.

“This grant will enable us to expand the project to more than a third of Nebraska’s small rural hospitals and to develop a toolkit for medication safety that can be replicated in similar-sized hospitals across the nation,” said Dr. Jones, director of the Small Rural Hospital Medical Error Reporting Project.

The Small Rural Hospital Medication Error Reporting project, which began in September 2001 with the voluntary participation of four critical access hospitals, has grown to include 14 small, rural hospitals across the state. Thirteen of the hospitals are critical access hospitals, which have 25 or fewer beds. Thanks to the grant, the program will expand to 24 rural hospitals in Nebraska and 10 to 12 in North Dakota.

The project provides patient safety education and assistance to build a reporting infrastructure that enables small rural hospitals to identify and correct the system causes of medication errors. “Rural hospitals have not had a consistent, valid mechanism to collect and analyze information about medication errors,” Dr. Jones said. “Our project is unique because it is geared to fit the needs of the nation’s smallest hospitals.”

The project provides a system of online data collection – more efficient and user friendly than the initial paper system — to categorize and track voluntarily reported medication errors. It also provides analysis of hospital “systems” and feedback on how to minimize organizational barriers to changing systems such as implementing medication reconciliation at admission, transfer and discharge.

Hospitals participating in the project voluntarily report their medication errors in a non-punitive culture, Dr. Jones said. “We emphasize that it isn’t about the person, it’s about improving the system,” she said.

Communicating how and why an error happened enables hospital personnel to identify where system breakdowns occur that contribute to errors, she said.

The Small Rural Hospital Medication Error Reporting project was developed after the Institute of Medicine’s (IOM) 1999 report, “To Err is Human: Building a Safer Health System.” The report estimated that upwards of 98,000 Americans die each year due to medical errors.

“Much of the research about patient safety has been done in large urban hospitals,” Dr. Jones said. “We wanted to understand how to make patient safety relevant to resource-deficient, small rural hospitals.”

The IOM has emphasized that for hospitals to achieve the six aims of quality care — safe, effective, patient-centered, timely, efficient, and equitable — they must enhance their quality improvement capabilities. Due to low operating margins and limited human resources, small rural hospitals have found it difficult to analyze and improve care using a systems approach. However, collaboration with larger organizations, such as academic medical centers, can help them overcome these barriers to quality improvement.

As a result, Dr. Jones; Dr. Mueller, principal investigator of the grant; and Stephen Smith, M.D., chief medical officer for The Nebraska Medical Center, began discussing patient safety issues with rural hospitals. From there, Dr. Jones, Dr. Cochran and Dr. Mueller, in collaboration with the Outcomes and Performance Improvement Department at The Nebraska Medical Center, established the project and reporting process.

Thanks to the project, participating hospitals have learned how to track and trend medication error reports by severity, type and cause to improve the system of medication use. The hospitals also have gained a better understanding of how their medication error reporting compares to their counterparts.

“Working with UNMC has helped us proceed with confidence in looking at our process of medication administration and to build a culture of safety,” said Lynda Zieg, quality management director at York General Hospital in York, Neb. “Using best practice as our goal, we have improved many aspects of our medication administration process.”

One example, Zieg said, is having the pharmacist add – to the computerized process for ordering meds from the pharmacy — the generic name of drugs to the list of brand name medications. This change assists the nursing staff and ward clerk to make the process easier and also prevents errors.

“Concentrating on processes and systems instead of human error has allowed us to share more openly,” Zieg said. “We have realized that when we share our experiences openly with each other, it helps us identify a kink in our system, which can be remedied.”

According to a 2004 national survey, 40 percent of the 1,085 critical access hospitals in the country have pharmacists on site fewer than 10 hours per week. As a result, pharmacists often aren’t available to verify the appropriateness of prescribed medications or to prepare and dispense medications. Out of 85 acute care hospitals in Nebraska, 60 are critical access, Dr. Jones said.

To lower the possibility of medication errors, Dr. Jones said, a few of the hospitals participating in the Small Rural Hospital Medication Error Reporting project have increased on-site pharmacy staffing, boosted the number of “double-checks” and defined “high-alert” medications, which are most likely to cause harm if administered improperly.

“Through our comprehensive approach to medication safety, we teach health care professionals that patient safety is part of the institution’s system and culture and not about the individuals,” Dr. Jones said. “We’re building a system that allows us to be human beings and makes it easier to do the right thing and harder to do the wrong thing.”

With the grant, project officials will create educational toolkits explaining how to best implement medication safety practices. In April, more than 100 health care professionals from 36 hospitals attended a daylong workshop, sponsored by UNMC and the Nebraska Hospital Association, regarding medication reconciliation — the process of comparing a patient’s newly ordered medications to those already being taken.

Creating the reporting infrastructure and culture to report medication errors benefits patients and health care providers, Dr. Jones said. “We wouldn’t walk onto an airplane if the pilot wasn’t going to complete his safety checklist,” she said. “In similar fashion, patients and health care professionals need a robust error reporting system that provides continuous feedback and the ability to improve the system to reduce and prevent medication errors.”