Pharmacists around the country now have one more administrative chore to worry about. Fortunately, this task concerns only their Medicaid patients—but that may be small comfort.
October 1, 2007, was the start date for a new federal requirement that pharmacists fill only those Medicaid prescriptions, including those for over-the-counter medications, that are written on “tamper-proof pads.
Problem: A hospitalized patient whose arm was connected to a portable blood pressure (BP) monitoring device was transported to the radiology department for magnetic resonance imaging (MRI). A length of tubing that led from the monitor’s BP cuff inflator had a male Luer connector. This connector fit into a female connector on a shorter length of white tubing that was integrated with a Critikon disposable BP cuff (Figure 1). The tubing and cuff were disconnected before the MRI procedure, because the Luer connector on the monitor’s tubing was metal.
PROMOTING A CULTURE OF SAFETY
A culture of fear stifles creativity and innovation, and it impedes continuous improvement by enabling defects to remain undetected—or unreported. Fear fosters gaps between “what we know” and “what we do.” To close this gap, it is imperative to promote and to support a culture in which staff members can search for defects and can continually seek and eliminate the flaws in the system. When employees are afraid or hesitant, productivity suffers. Fear drives people to remove the source of fear, not the source of the problem. Improved performance cannot occur unless staff members feel comfortable in reporting defects and speaking truthfully and are confident thattheir suggestions will be taken seriously.
In the 2005 Patient Safety Culture Survey (total respondents = 601), the staff gave VA-NYHHS a mean patient safety grade of 3.97 (acceptable, borderline very good), which was higher than the means of the Veterans Integrated Service Network (VISN 3) (3.89) and the VA nationally (3.87). Despite that high overall grade, the NYHHS grade was below the VA national mean for the following patient safety dimensions: Nonpunitive Response to Error (-0.86) and Perceptions of Patient Safety at Your Facility (-0.12). These results indicated that the VA-NYHHS staff was still associating incident reporting with punitive consequences.
In October 2006, several nurses, pharmacists and providers commented that the medication error-reporting process at the Veterans Affairs-New York Harbor Healthcare System (VA-NYHHS) was lengthy and cumbersome and did not promote the reporting of all medication close calls and adverse events. The staff’s concerns were validated by the medication error-reporting data.
INTRODUCTION
According to the Institute of Medicine’s (IOM’s) 1999 report, To Err Is Human: Building a Safer Health System, between 44,000 and 98,000 patients die each year in hospitals as a result of medical errors, thereby making these misadventures the eighth leading cause of death. With an estimated cost of $17 to $29 billion each year, 38% of these mistakes are errors in drug administration, and only 2% of these errors are intercepted. These findings have spurred the nation to make patient safety a key issue and to move toward improvement. Since realizing that medical errors have been underreported, the IOM has recommended establishing error-reporting systems that can help identify errors and allow hospitals to learn from these mistakes.
The most surprising finding of this investigation was that most neonates with respiratory symptoms were not classifiable by standard diagnostic criteria for textbook pulmonary disorders, even applying the broadest definitions. To our knowledge, this is the first attempt to classify acute respiratory disorders in the newborn in three decades in North America. Interestingly, similar to the findings of Hjalmarson in Sweden 21 years ago, a large proportion of infants with respiratory symptoms fail to meet any diagnostic criteria for the respiratory conditions as defined in standard textbooks. Nevertheless, they are ill and in many cases present with frank respiratory failure.
During the one year enrollment period, there were 2805 live-born infants weighing at least 500 grams born without major anomalies in our hospital. We excluded 19 live-born infants from the study because of birth weights below 500 grams (15 infants) or congenital anomalies (four infants). Three were excluded for incomplete data. Of the study population, some 584 (21%) developed one or more respiratory signs in the first day, 90% of them within the first hour. The respiratory distress persisted beyond six hours in 474 (81%) of the symptomatic neonates and 400 (68%) were admitted to the neonatal intensive care unit. There were 19 deaths among these infants in the first five days of life, 12 in infants with RDS, giving an overall five-day mortality rate of 32/1000 for all infants with respiratory symptoms and a five-day case fatality rate of 111/1000 for the subset with RDS. Additional early neonatal deaths occurred in our inborn population over the study period: one infant with holoprosencephaly and all 15 infants with birth weights below 500 grams.
