{"id":11160,"date":"2012-01-07T10:23:09","date_gmt":"2012-01-07T15:23:09","guid":{"rendered":"http:\/\/pmedicine.org\/epatients\/?p=11160"},"modified":"2012-01-07T15:03:23","modified_gmt":"2012-01-07T20:03:23","slug":"star-tribune-simple-pharmacy-change-produces-major-quality-improvement","status":"publish","type":"post","link":"https:\/\/participatorymedicine.org\/epatients\/2012\/01\/star-tribune-simple-pharmacy-change-produces-major-quality-improvement.html","title":{"rendered":"Star Tribune: Simple pharmacy change produces major quality improvement"},"content":{"rendered":"

\"Doctors<\/a>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 <\/em>documented the high rate of deaths <\/em>from\u00a0medical errors in U.S. hospitals. (Not just mistakes, but deaths <\/em>from mistakes. If accidental death in a hospital isn’t ironic, I don’t know what is.)<\/p>\n

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<\/strong> die<\/em>\u00a0from accidental causes. (See Jon Lebkowsky’s post<\/a>\u00a0about it, from a Consumers Union Safe Patient Project meeting where he spoke.)<\/p>\n

We’re in our 13th year after To Err<\/em>, yet this morning SPM member Paul Bearman spotted this article<\/a>\u00a0by Maura Lerner in the Minneapolis Star Tribune<\/em> and posted a note on our member listserv. From Paul’s note:<\/p>\n

… minor changes\u00a0resulted in\u00a0major improvement\u00a0of a critical element in patient care.<\/p>\n

What I love about the story is how\u00a0intelligent change can\u00a0be so wonderfully effective.\u00a0\u00a0 A small\u00a0tweak reversed critical failures in\u00a0discharge prescribing. \u00a0 No \u00a0complex, expensive, \u00a0and\u00a0difficult to use\u00a0technologies\u00a0were used.\u00a0 Instead there was a basic trust people given the right structure\u00a0to do the right thing will get it right.<\/p><\/blockquote>\n

The change agent in this case was Bruce Thompson, the hospital’s pharmacy director<\/em>. From the article:<\/p>\n

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.<\/p>\n

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

The most common problems: Hospital physicians had prescribed the wrong doses, duplicate medications or omitted medications. Nearly a third were considered “likely harmful.”<\/p><\/blockquote>\n

Yikes! \u00a092% wrong?? \u00a0A third of them (30% of all scripts) likely harmful<\/em>??<\/p>\n

What’s the miracle fix?<\/p>\n

…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.<\/p>\n

In nine months, the error rate dropped to “essentially zero percent”… that, in turn, cut the 30-day readmission rate… in half<\/p><\/blockquote>\n

And, deliciously, this:<\/p>\n

The project worked so well, Thompson said, that some doctors now call the pharmacist\u00a0before<\/em>\u00a0they write the discharge orders.<\/p><\/blockquote>\n

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.<\/p>\n

Nearly zero percent! \u00a0Nearly total reduction in “likely harmful” prescription errors!<\/p>\n

What’s an e-patient to do?<\/p>\n