Six or seven flights ago, a young woman holding a Costco-sized jar of earplugs stood up as I approached my row.

“Would you like a pair?”

“No, but thanks.”

“You sure? We have an infant.”

People who say they sleep like a baby probably don’t have one. Thank God this baby napped from takeoff to touchdown. Not a peep. Precious child.

For me, babies screaming are nails on a flight’s chalkboard. So are men snoring. So far this trip so good. Knock on aluminum.

I suppose parents have an appropriate time to defend a child’s obnoxious behavior with, “He needs a nap.” But I feel this overused defense is generally a lame justification for inexcusable behavior, especially as the kid grows older. Some of us retain the right to offer the excuse into our adult years as if we are under no obligation to be nice when we don’t get a full eight hours.

I’ve never worked in a hospital, but I understand fatigue from long shifts, back-to-backs, double shifts, and understaffing can incubate some challenging social interactions.

Somewhere along the line, I was taught that we can and should learn to be nice even when we are tired. However, no matter how nice we may be, we still owe it to others, not just to ourselves, to make sure we get adequate sleep. Truck drivers owe it to travellers on the highways. Pilots and flight crews owe it to passengers on their flights. Doctors, nurses, and pharmacists owe it to patients in their hospitals.

I’ve been blessed to meet and interview Eric Cropp, RPh, and Julie Thao, RN, two phenomenal people, each involved in a medication error that took the life of a patient. Eric and Julie entered their professions to make a difference, to care for patients, to do no harm. In addition to a confluence of human and system errors, both tragedies involved multiple-shift weariness

Truthfully, I’m tired. April included a heavy consulting load with lots of travel. Add preparing for The unSUMMIT for Bedside Barcoding, which concluded a few days ago—our best of seven, by the way. Yesterday I flew five hours from Seattle to Washington DC. Equipment failure forced us to stay overnight near Dulles before boarding a rescheduled flight to Brazil. Though I’ve grown weary from well doing, I need some sleep.

My favorite New Yorker cartoon depicts a collie standing by a man who has fallen and can’t get up. In the first frame, the man cries, “Lassie, get help!” In the second frame, Lassie is lying on a psychiatrist’s couch.

Unfortunately and fortunately, I’ve flown enough miles to be upgraded to a business-class seat, which transforms into a flat bed. There’s a chance my presentation in English to a Portuguese-speaking audience will make better sense if I lie down and steer clear of the Bermuda Triangle of meals, mojitos, and movies.

Someone is counting on my rest. I just hope I don’t snore. Someone’s counting on your rest, too.

Assuming you are still awake, what do you think?

Mark Neuenschwander (a.k.a. Noosh)

“The analysis focused on 11 quality indicators (January-December 2009) at 2603 medium-to-large (=100 beds), non-federal acute-care hospitals measuring proportion of eligible patients given (or prescribed) recommended medications for conditions, including acute myocardial infarction, heart failure, and pneumonia, and surgical care improvement. Using technology adoption by 2008 as reference, hospitals were coded: (1) eMAR-only adopters (n=986); (2) CPOE-only adopters (n=115); and (3) adopters of both technologies (n=804); with non-adopters of both technologies as reference group (n=698). Hospitals were also coded for duration of use in 2-year increments since technology adoption. Hospital characteristics, historical measure-specific patient volume, and propensity scores for technology adoption were used to control for confounding factors. The analysis was performed using a generalized linear model (logit link and binomial family). Principal findings Relative to non-adopters of both eMAR and CPOE, the odds of adherence to all measures (except one) were higher by 14-29% for eMAR-only hospitals and by 13-38% for hospitals with both technologies, translating to a marginal increase of 0.4-2.0 percentage points. Further, each additional 2 years of technology use was associated with 6-15% higher odds of compliance on all medication measures for eMAR-only hospitals and users of both technologies. Conclusions Implementation and duration of use of health information technologies are associated with improved adherence to medication guidelines at US hospitals,” wrote A. Appari and colleagues, Dartmouth College (see also Health Information Technology).

The researchers concluded: “The benefits are evident for adoption of eMAR systems alone and in combination with CPOE.”

Appari and colleagues published the results of their research in the Journal of the American Medical Informatics Association (Medication administration quality and health information technology: a national study of US hospitals. Journal of the American Medical Informatics Association, 2012;19(3):360-7).

Smart infusion pumps help prevent medication errors by alerting healthcare professionals about pump settings that don’t match their facility’s drug administration guidelines. The smart pump’s software has a drug library that issues an alert if a programmed infusion is outside of recommended parameters for a certain drug. Traditional infusion pumps are more likely to encounter errors because they were manually programmed.

According to the KLAS report, drug libraries and continuous quality improvement (CQI) data are designed to make smart pumps smart. However, drug libraries can be bypassed, which is why wireless technology is valuable: it can supply providers with information and enable them to improve how they administer IVs.

[ Is it time to re-engineer your clinical decision support system? See 10 Innovative Clinical Decision Support Programs . ]

For health systems, integrating smart pumps with EMRs can be a challenge, in part because hospitals need the infrastructure to support the pumps. “Historically the pump was wireless but didn’t need to maintain wireless connectivity 24/7. [Connectivity] was only needed for reports and drug library downloads,” Kristen O’Shea, clinical transformation officer for WellSpan Health, and VP for patient care services at Gettysburg Hospital in Gettysburg, Pa., told InformationWeek Healthcare. Wellspan was one of the respondents in the KLAS survey, and one of the few providers who have taken definitive action to integrate smart pumps.

But, O’Shea pointed out, 24/7 bi-directional communication between the smart infusion pump and the EMR is now needed. This is complex and requires a team approach. “Each member of the team needs to understand implications. The clinical analysts needed to make sure the medication order sentences in the electronic record were consistent with drug library settings on the pump. There are lots of important connections so we all need to be working closely so as to not interrupt any processes.” WellSpan has created a new hybrid biomedical/IT position to manage device connectivity, said O’Shea.

Wireless EMR-pump integration has been implemented in 90 beds within the WellSpan system and it expects to expand implementation later this summer. Hospira provides the pump technology and Cerner is WellSpan’s EMR vendor.

Mark Neuenschwander, president of The Neuenschwander Company and co-founder of the unSUMMIT for Bedside Barcoding, said that auto-programming from EMRs to pumps reduces pump programming errors. “Real-time data transmission from pumps to EMRs increases accuracy of documentation, notifies pharmacy of activity, warning them of interruption, notifying them that the administration is almost complete and a new IV needs to be prepared and sent,” Neuenschwander said.

According to the KLAS report, Cerner is the only vendor that has taken an active role in working with all pump vendors. Cerner has integration alliances with CareFusion, Hospira, and B. Braun. Epic is working on an EMR integration initiative with CareFusion. Allscripts, GE, McKesson Meditech, and Siemens have not engaged in EMR integration; however, Allscripts reports that it has a site in process, according to KLAS.

Wireless technology, according to the report, allows for more-frequent adjustments to the drug libraries based on report data and a more-automated process to push updates to pumps. The report states that providers that use wireless technology were “45% more likely to actively use report data and 39% more likely to know drug library compliance rates.”

“You can choose to purchase a smart pump without wireless capabilities, much like you can buy a computer with wired, wireless, or no network capabilities,” Coray Tate, VP of clinical research at KLAS and lead author of the report told InformationWeek Healthcare.

Tate added that wireless allows you to pull usage reports from the smart pump that show how nursing staff is using and complying with the safety features of the pump. “It also allows them to make changes to the drug libraries and push those changes out to each pump. CareFusion, Hospira, and Baxter all have a significant portion of their customers using wireless technology. Since it was only recently cleared by the FDA, only a few of the B. Braun and Smiths customers are using wireless,” Tate said.

Providers who participated in the survey said they were ready to take the next step of EMR integration, with one in four saying that they were “either actively pursuing pump/EMR integration or listed it as a top priority.” One-quarter said that EMR integration was important but that it took a back seat to meaningful use, while half of the providers said that EMR integration should be part of meaningful use requirements.

KLAS’s Tate said that the biggest takeaway from the report is that when it comes to EMR integration, the industry is moving in the right direction. “For the past several years there’s been three or four sites that have been doing this integration or some level of EMR integration. The thing that was revealing this year, there’s six now, but there’s a chance that by the end of the year that could be pushing 20,” Tate said.

The 2012 InformationWeek Healthcare IT Priorities Survey finds that grabbing federal incentive dollars and meeting pay-for-performance mandates are the top issues facing IT execs. Find out more in the new, all-digital Time To Deliver issue of InformationWeek Healthcare. (Free registration required.)

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According to the Institute of Medicine, medication errors contribute to the 400,000 preventable drug-related injuries and 7,000 drug-related deaths which occur each year in U.S. hospitals. Barcode scanning of patients, medications, laboratory specimens and blood products at the point of care, combined with pharmacy and nursing best practices, prevents harm to patients and saves lives.

Each year, The unSUMMIT community nominates and honors the exceptional contributions of individuals and institutions who have helped clear the path and accelerate the adoption of BPOC safety systems in hospitals across North America. This year’s Way-Paver Awards will be presented to recipients on May 2, 2012 in the following categories:

HOSPITAL—University of Wisconsin Hospital and Clinics, Madison WI

For two decades, the Hospital and Clinics (UWHC) has been a thought leader and early adopter of barcode technology and automation designed to create a safer medication use process. Along the way, the hospital has rigorously studied the before-and-after impact of barcode technology on patient safety, utilizing their findings to continuously improve quality of care.

In 1993 UWHC was the second hospital in America to use barcode driven robotics for dispensing medications, realizing a reduction of 24,000 dispensing errors per year.

In 2001, UWHC began a house-wide implementation of barcode medication administration (BCMA). Using blind-naïve direct-observation and event-reporting methods, UWHC’s research revealed an 87% reduction in medication administration error rates translating into over 300,000 errors avoided per year.

Over the years, UWHC has been generous and transparent in sharing their successes and challenges with colleagues across the country via countless presentations and articles as well as hosting site visits and vendor summits for technology improvement.

INDIVIDUAL—Judy Smetzer, RN, BSN

Since 1998, Judy Smetzer, a vice president of the Institute for Safe Medication practice (ISMP), has diligently served as editor of ISMP Medication Safety Alerts—a publication read by thousands of clinicians in essentially all US hospitals and influential with accreditation organizations and regulatory authorities including The Joint Commission, FDA, CMS, and CDC.

Her July 25, 2001 Safety Alert, “The supermarkets do it – so why can’t we raise the “bar” in health care?” was an early and clear call to hospitals to implement BCMA. Additionally, Smetzer was a leader in publishing the invaluable assessment tool for hospitals preparing for BCMA: Pathways for Medication Safety: Assessing Bedside Bar Coding Readiness. 

Smetzer’s articles, commentaries, news briefs, press releases and testimonies related to BCMA (approaching the 200 mark) not only compel hospitals to use BCMA but use it the right way. She has not hesitated to point out dangerous unintended consequences of poorly designed or improperly used technology and to identify and share remedies.

More than 50 leaders will share the barcoding experience of institutions including Brigham and Women’s Hospital, Veterans Health Administration, Hospital Corporation of America (HCA), Vanderbilt University Medical Center, WellSpan Health, Lahey Medical Center, and Lancaster General Hospital. The full three-day conference agenda may be viewed at: http://www.unsummit.com/pdf/unSUMMIT2012brochure.pdf

About the Way-Paver Award

The Way-Paver Award was established by The TerraPharma Project in 2006 to honor the exceptional contributions of individuals and institutions that have helped clear the path and accelerate the adoption of BPOC technologies in hospitals across North America. Previous institutional recipients include Brigham and Women’s Hospital, Hospital Corporation of America, Veterans Health Administration, Lancaster General Hospital, WellSpan Health, Southwestern Vermont Medical Center, and the FDA. Previous individual recipients include Michael Cohen, founder of the Institute for Safe Medication Practices (ISMP), Kenneth Barker of Auburn University, John Roberts of GS1 US Healthcare, and John Santell of US Pharmacopeia. To learn more about the award, go to unsummit.com.

About TerraPharma Project LLC

The TerraPharma Project, LLC (TTP) of Bellevue, WA, is a peer-to-peer education exchange, fueled by the conviction that barcode point-of-care (BPOC) technology is low-hanging fruit that delivers high returns for patient safety. Committed to promoting the adoption of BPOC in hospitals across the nation, TTP produces The unSUMMIT for Bedside Barcoding (http://www.unsummit.com) and the online Point of Care Forum (www.pointofcareforum.com).

Media Contact

For media questions related to The unSUMMIT or the Way-Paver Awards, please contact TTP Co-Founder, Mark Neuenschwander, at mark@unsummit.com or 425 644-6797

Author Affiliations: Clinical Nurse Specialists (Mss Richardson and Bromirski) and Patient Safety and Quality Specialist (Dr Hayden), Southwestern Vermont Medical Center, Bennington.

Abstract

PURPOSE/OBJECTIVES:
The goal of this article was to outline a process change in medication administration using technology and led by clinical nurse specialists (CNSs) that has been successful and sustainable over time.

BACKGROUND/RATIONALE:
The Institute of Medicine published a landmark report in September 1999 estimating that between 44 000 and 98 000 patients die each year because of medical errors. Errors are rarely the result of incompetent individuals using intentionally unsafe practices. Instead, errors usually result from poorly designed systems that do not prevent errors from occurring. Medication administration is an example of a multistep system that, because of its complexity, can be a challenge to accomplish safely and without error. It is estimated that errors from medication administration have led to 7000 deaths per year.

DESCRIPTION OF THE PROJECT/INNOVATION:
Using an electronic medication administration record with bar-code scanning for both patient and medication verification at the bedside is a technological methodology known to enhance medication administration safety. Many organizations have adopted these technologies, but not all have shown exceptional and sustained successes leading to a safer hospital experience for their patients. This article outlines the key steps that guided the CNSs from a small Magnet-designated New England hospital to improve medication administration safety. The project improvements were framed in the methods of reliability science.

OUTCOME:
The article describes a practice change for nurses and pharmacists that resulted in sustained bedside medication scan rates of greater than 97% and medication error reduction from 2.89 errors per 10 000 doses before implementation of electronic medication administration record to a current rate of 1.48 errors per 10 000 doses.

INTERPRETATION/CONCLUSION:
This improvement project demonstrates that CNSs can play a vital role in bringing electronic medication administration to the hospital environment. The CNS leaders established a network of relationships with experts in pharmacy, information technology, and patient safety to address the varied stakeholder interests.

1. Craig A. Pedersen⇓,
2. Philip J. Schneider and
3. Douglas J. Scheckelhoff

Abstract

Purpose Results of the 2011 ASHP national survey of pharmacy practice in hospital settings that pertain to dispensing and administration are presented.

Methods A stratified random sample of pharmacy directors at 1401 general and children’s medical-surgical hospitals in the United States were surveyed by mail.

Results In this national probability sample survey, the response rate was 40.1%. Decentralization of the medication-use system continues, with 40% of hospitals using a decentralized system and 58% of hospitals planning to use a decentralized model in the future. Automated dispensing cabinets were used by 89% of hospitals, robots were used by 11%, carousels were used in 18%, and machine-readable coding was used in 34% of hospitals to verify doses before dispensing. Overall, 65% of hospitals had a United States Pharmacopeia chapter 797 compliant cleanroom for compounding sterile preparations. Medication administration records (MARs) have become increasingly computerized, with 67% of hospitals using electronic MARs. Bar-code-assisted medication administration was used in 50% of hospitals, and 68% of hospitals had smart infusion pumps. Health information is becoming more electronic, with 67% of hospitals having partially or completely implemented an electronic health record and 34% of hospitals having computerized prescriber order entry. The use of these technologies has substantially increased over the past year. The average number of full-time equivalent staff per 100 occupied beds averaged 17.5 for pharmacists and 15.0 for technicians. Directors of pharmacy reported declining vacancy rates for pharmacists.

Conclusion Pharmacists continue to improve medication use at the dispensing and administration steps of the medication-use system. The adoption of new technology is changing the philosophy of medication distribution, and health information is rapidly becoming electronic.

CMS is accepting comments on the proposed rule until May 7, 2012. Please share specific safety benefits that your institution has realized with BCMA. To submit electronic comments go to http://www.regulations.gov/#!submitComment;D=CMS-2012-0022-0001 and complete the short form.

Brian Goldman, an ER physician from Toronto, is host of the award-winning White Coat, Black Art on CBC Radio and slated to deliver the keynote at The unSUMMIT for Bedside Barcoding in Anaheim this May. His TED lecture, entitled, “Doctors make mistakes. Can we talk about it?” had already been viewed by 386,072 others before I watched it last week.

Articulately and humbly, the physician talks openly about several serious and potentially serious medical errors he has made over his career and how the prospect for more errors lingers: “I’d like to be able to say to you that my worst mistakes only happened in my first five years of practice (as some of my colleagues say, which is total BS). But some of my doozies have happened in the last five years.”

I first heard the now-tired joke from an RN: A nurse dies and goes to heaven where she’s greeted by St. Peter. Over his shoulder she spots a man in a white coat with a stethoscope around his neck. She protests, “There are doctors in heaven?” Peter answers, “No, that’s God. He just thinks he’s a doctor.”

The fact is, nurses and doctors have this in common (with the rest of us, I might add): We are human and make mistakes, which we find difficult to admit.

Four centuries before it appeared as the title of the Institute of Medicine’s landmark report on medication errors, To Err is Human was the first half of Alexander Pope’s trustworthy maxim: “To err is human, to forgive divine.”

I found Dr. Goldman’s 19-minute lecture on YouTube refreshingly human—free from God-playing­­­­—especially juxtaposed to Steve Jobs by Walter Isaacson, the iBook version of which I am reading on my resolutionary new iPad.

Don’t get me wrong. I think Jobs was brilliant and incredibly productive. The fruit of his labor has proven inestimably valuable to me personally. At the end of my October 2011 I’ve been thinking, I added a postscript:

An hour ago, on a device invented by Steve Jobs, I learned of his death. I’m sad. I’m also grateful for how I have benefitted from his genius and life work. Pecking out these thoughts on a MacBook Pro, I confess that I lean hopelessly on the side of the brain that can’t remember which side is creative. Jobs opened the technology door for my kind of brain to enter and flourish. Yes, I am grateful.

Having said that, Jobs was a piece of work whose Zen-like results failed to justify his oft-inhumane means. Steve’s closest friends and bitterest enemies concurred that he lived much of his life in a “reality distortion field,” at the root of which was his belief that the rules did not apply to him. (I’m rewriting that classic heaven joke in my head.)

Insisting on playing by his own rules made it difficult for the legend from Cupertino to discern when he had made a mistake, wronged and hurt others or to admit if he had, let alone to make things right. After recalling Steve’s brutal defamation of the mother of his first child, Isaacson writes, “Years later Jobs was remorseful for the way he behaved, one of the few times in his life he admitted as much.” Given the abundance of forgiveness he needed for his own hurtful behaviors, Steve did not appear overly quick to forgive those who hurt him. Isaacson notes, “Jobs held grudges, sometimes passionately.”

One of the surprises in reading his biography is that I’m seeing more Steve Jobs in me than my penchant for wearing black shirts (a rut into which I fell before he did). Characteristics I share with his lighter side are affirming, if sometimes quirky, like his appreciation for simplicity and beauty, his refusal to sacrifice either form or function, his search for the perfect metaphor[1], and taking years to decide which couch to purchase. With Job’s darker side—lets just say that I wish I could leave acting like the arrogant, unforgiving, grudge-holding billionaire completely up to Ashton Kutcher, who today it was announced will play the Hollywood production of the Apple founder’s life.

Back to Alexander Pope. I wonder if he was appealing for a different kind of God playing with, “to forgive, divine?”

Benjamin Franklin, another biography Isaacson tackled, crafted an intriguing variation of the maxim: “To err is human, to repent divine, to persist devilish.”

Dr. Goldman plays by the rules for all the right reasons. He says, “If I can’t come clean and admit my mistakes, how can I share them with my colleagues . . . so they won’t do the same thing?” He also makes a case for transparency fostering the creation of backups (think technology) that make it easier to detect the persistent mistakes that humans inevitably make so they can be avoided.

Few have done as well with merging technology and art as the late CEO of the world’s most valuable company. Nevertheless, I imagine he could have accomplished still more by blending his complex passion for perfection with simple humility—not unlike the bright humble Canadian ER doc appears to be doing. Then again, I could be wrong.

In any instance, astounding as his accomplishments may be, Steve Jobs (nine years my junior) reminds me that life is short—too short for devilish persistence in always having to be right. And I’m pretty sure I’m right about that.

What do you think?

Mark Neuenschwander (a.k.a. Noosh)

Link: https://secure.quantiamd.com/player/mgffcsd?cid=34&u=yvcuhbzez&partner=linkedin&la=EN&country=US

But the mud that stuck to my wall was the climax: “You’ll pay me back in kind and reap just what you’ve sown.”

I knew a guy in college who figured he’d sow wild oats all week then go to church on Sunday and pray for crop failure. Nice try. In The Wealth of Nations, Adam Smith highlighted the flip side of the coin in observing that people “love to reap where they never sowed.”

Admittedly, my youthful musings on the law of the harvest focused more on the negative (refraining from sowing bad seed) than on the positive (making sure I was sowing good seed).

I have not been mesmerized by my Mariners, who for the past few decades failed to sow talent. When Jack Zduriencik (fans call him “Z”) took over as general manager in 2008, local sports writers noted that he was handed a “barren farm system.” The M’s were reaping just what they had sown—not much.

Before coming to Seattle, Z helped hoe the rows of Milwaukee’s farm system. It took seven years for the Brewers to grow into a pennant contender, producing six National League All Stars.

Ten games into spring training, we are starting to see the fruit of Z’s labor. The youngsters’ arms are smoking, and their bats are coming alive. They’ve won seven. We’re looking toward the harvest.

Speaking of baseball makes me think of the Brigham and Women’s Hospital a mile down Brookline from the legendary Fenway Park, home of the Boston Red Sox. The Brigham, which started scanning bar-coded patients and medications at the point of care in 2003, is reaping improved patient and caregiver safety. Their chief of pharmacy, Bill Churchill, tells me that with bar-code medication administration (BCMA), Brigham is preventing more than 90,000 medication errors annually. That’s a bumper crop.

It’s never too late to start sowing. Is your hospital preparing for BCMA? Here is a great bibliography from The American Society of Health-System Pharmacists to get you started.

However seasoned hospitals are in the BCMA game, The unSUMMIT for Bedside Barcoding has proven to be an invaluable spring-training ritual for many to hone their skills.

The Brigham’s program director for clinical systems innovations and medication safety, Anne Bane (a dyed-in-the-wool Red Sox and BCMA fan), has been to most of The unSUMMITs. Anne is one of our all-star presenters and will step up to the plate again this May 2-4 in Anaheim. I asked this ten-year bar-coding veteran why she still comes to these meetings. Her reply:

I can go to many other conferences to learn how a piece of technology or an application works. But at the unSUMMIT, I learn how to apply the technology in clinical practice and what benefits it brings to the patients and nurses. Best to learn from others who are doing the same thing I do every day!

The sooner hospitals sow BCMA, the sooner they harvest the rewards. Adele is right; we reap just what we’ve sown—no more, no less. Maybe we can’t have it all, but why have regrets over what could have been (e.g., errors prevented, harm avoided, lives saved, and careers protected)?

As the Good Book says, “Let us not become weary in doing good, for at the proper time we will reap a harvest if we do not give up.”

Hope to see you in Anaheim,

Mark Neuenschwander (a.k.a. Noosh)

P.S. Send a brochure to a colleague you think would benefit from The unSUMMIT. Download a brochure for yourself.