For instance, hospital teams followed standard protocols for weaning patients off long-term doses of opiates. They reduced prescription overrides in which nurses gave pain medications to children before double-checking with a pharmacist. And they worked hard to ensure that all caregivers had up-to-date drug lists when patients were admitted to hospital, transferred to new wards and sent home. The study physicians also routinely added medications to prevent constipation.
"Our focus was not only on errors, but also on harm to patients," said Frank Federico, the study's senior author, who is a pharmacist and medication safety expert with the Institute for Healthcare Improvement in Cambridge, Mass. Patients can be harmed by correctly dosed medications, but in the past that hasn't always been considered a problem. For example, many health-care providers may view constipation as simply "the cost of doing business" when opiates are given to children, Federico said. In this study, physicians instead headed off constipation by starting patients on laxatives and stool softeners as soon as they began opiate prescriptions.
The research team checked its progress with quarterly reviews of patient charts at each hospital. In chart reviews, investigators looked for specific clues that a patient had been harmed by opiates. If they found a clue such as a prescription for naloxone, a drug given to reverse the effects of opiates they read the chart more thoroughly for signs the patient was harmed.
The researchers' efforts began paying off a few months after changes were instituted. Problems associated with opiates dropped, as the new practices spread through each hospital. In total, the team estimated 14,594 harmful events were averted in partic
|Contact: Erin Digitale|
Stanford University Medical Center