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Doctors discussing prescription errors (and having a hard time reading the report)We often note here that quality improvement in hospitals seems excruciatingly slow to happen, and engaged patients and families need to keep their eyes wide open, because sometimes a fix doesn’t require being a genius. For instance, see the cartoon at right – from 1999, when the Institute of Medicine’s famous report To Err is Human documented the high rate of deaths from medical errors in U.S. hospitals. (Not just mistakes, but deaths from mistakes. If accidental death in a hospital isn’t ironic, I don’t know what is.)

Nobody likes to think about it, but the vast majority of hospitals haven’t fixed this: a year ago the HHS Inspector General reported that 15,000 Medicare patients a month die from accidental causes. (See Jon Lebkowsky’s post about it, from a Consumers Union Safe Patient Project meeting where he spoke.)

We’re in our 13th year after To Err, yet this morning SPM member Paul Bearman spotted this article by Maura Lerner in the Minneapolis Star Tribune and posted a note on our member listserv. From Paul’s note:

… minor changes resulted in major improvement of a critical element in patient care.

What I love about the story is how intelligent change can be so wonderfully effective.   A small tweak reversed critical failures in discharge prescribing.   No  complex, expensive,  and difficult to use technologies were used.  Instead there was a basic trust people given the right structure to do the right thing will get it right.

The change agent in this case was Bruce Thompson, the hospital’s pharmacy director. From the article:

He and his colleagues decided to do a spot-check of 37 patients who were discharged from the hospital to nursing homes over three months in 2008 and 2009.

The rate of medication errors: 92 percent. “It was alarming,” he said. Only three of the 37 cases were problem-free.

The most common problems: Hospital physicians had prescribed the wrong doses, duplicate medications or omitted medications. Nearly a third were considered “likely harmful.”

Yikes!  92% wrong??  A third of them (30% of all scripts) likely harmful??

What’s the miracle fix?

…the hospital assigned pharmacists to check the discharge orders before patients are released. Now, if they spot a mistake, they contact the physician and straighten it out.

In nine months, the error rate dropped to “essentially zero percent”… that, in turn, cut the 30-day readmission rate… in half

And, deliciously, this:

The project worked so well, Thompson said, that some doctors now call the pharmacist before they write the discharge orders.

I don’t know if they realized it, but that’s the Lean principle of “quality at the source” – getting it right the first time, instead of checking for errors later.

Nearly zero percent!  Nearly total reduction in “likely harmful” prescription errors!

What’s an e-patient to do?

  • Check, check, and re-check that everything’s going on – especially pharmacy orders.
  • Share the Star Tribune article with your hospital (and nursing home’s) pharmacy staff.
    • I personally know of two cases in my own family, in the past year, where medications were overlooked or wrong at discharge.
    • In my experience most people are happy to do a simple change that improves things. (And if they aren’t interested, that ought to tell you something about that place.)

Kudos to Bruce Thompson and team at Hennepin County Medical Center – and to all the people there who gladly adopted the change. I bet there’s been at least one funeral prevented already.


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