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It is painfully obvious that we are as yet nowhere near a solution, even for the so called “high alert” medications! According to the 2006 Institute of Medicine Report “Preventing Medical Errors,” on average, a hospitalized patient is subject to at least 1 medication error per day, with at least 1.5 million preventable adverse drug reactions occurring each year. According to an analysis of over 73,000 intravenous drug errors reported to the US Pharmacopoeia MedMarx database between 2000 and 2004, more than 50% of errors were in the process of actually administering medications, and 60% of these errors occurred in the intravenous administration of 1 of 20 “high alert” medications (Table 1).
In order to save lives and prevent harm to patients, far reaching changes are needed in the way medications are prepared and administered. Representatives of these and other national organizations joined in an intensive 2-day Intravenous Safety Summit convened by the American Society of Health System Pharmacists (ASHP) in Rockville, MD, on July 14-15 to recommend very specific and attainable changes in practice that will be effective in preventing medication errors and saving lives now lost to adverse drug events. Simplifying the administration process, with preference for the preparation of intravenous medication in the pharmacy rather than at the point of care. Obtaining the maximum benefit from technology in the form of bar codes, computerized order entry, and smart pumps. The specialty of anesthesiology and the practice of nurse anesthesia are both in very good positions to take leading roles in research, practice changes, and cultural changes needed to save lives now lost due to medication errors.
Establishing a “culture of safety,” however, may be more difficult than developing technology. Therefore, as a very important next step, the Anesthesia Patient Safety Foundation is planning a Board of Directors’ Workshop for Friday, October 17 in Orlando, FL, entitled “Innovations in Medication Safety in the Operating Room.” The workshop is designed to identify solutions for medication errors in the operating room that are currently technologically feasible, as well as ideas for potential new processes to be developed and explored. The Department of Diagnostic Imaging (DI) relentlessly pursues innovative solutions to meet the needs of each and every patient and achieve the highest quality of patient care.
Current thinking about patient safety is primarily focused on the immediate consequences of mistakes that affect care, such as medication errors. However, partly because of the huge number of doses and the number of different medications given daily, errors in IV medication administration still represent a significant health care problem in the United States today. The administration of flush solution with a heparin concentration 1000-times that intended to 17 Texas neonates in Corpus Christi on July 4 this year is just one very recent example of how far we have to go. These reactions lead to an estimated $3.5 billion in additional health care costs annually to hospitalized patients alone, and reactions to drugs represent between the fourth and sixth leading cause of deaths in hospitalized patients. However, 5% occurred in the operating room or in the pre- or post-anesthesia care units, where anesthesiologists and nurse anesthetists routinely practice. The persistence of the problem has led to a new sense of urgency on the part of many organizations dedicated to patient safety, including the Institute of Medicine (IOM), the Institute for Safe Medical Practice (ISMP), Emergency Care Research Institute (ECRI), Joint Commission, Food and Drug Administration (FDA), Centers for Medicaid and Medicare Services (CMS), National Patient Safety Foundation (NPSF), United States Pharmacopeia (USP), Agency for Healthcare Research and Quality (AHRQ), the Institute For Healthcare Improvement (IHI), the National Quality Forum (NQF), and many other professional and specialty organizations. One of the real strengths of this summit was the integral involvement of frontline practitioners—nurses, physicians, and pharmacists, as well as vendors, health system experts, and researchers.
Anesthesiologists are one of the few groups of physicians who are personally responsible for drug administration. Stabile, Webster, and Merry, in the Fall 2007 issue of the Anesthesia Patient Safety Foundation Newsletter, called for just such a cultural shift in medicine, from a culture of productivity to a culture of safety.

Participants in this workshop will include physicians, pharmacists, health systems and technology researchers, as well as representatives from the Joint Commission and other regulatory agencies. Martin is Professor of Anesthesia at Penn State University College of Medicine in Hershey, PA.
Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database. A new, safety-oriented, integrated drug administration and automated anesthesia record system. Evaluation in an anaesthetic simulator of a prototype of a new drug administration system designed to reduce error. We are committed to the provision of exceptional services while recognizing and respecting the diversity of the patients and other customers we serve.
It is conceptualized as a tiered diagram, presenting four levels that are potential threats to patients’ safety. It has been almost 9 years since the Institute of Medicine’s Report “To Err is Human” shocked the public consciousness and the medical establishment in 1999.1 Since then, much has been said and written about the problem, and there have been some significant steps forward.
In the operating room, it has been estimated that 1 drug administration error occurs for every 133 anesthetics.2 Approximately 1% of these errors actually cause patient harm.
Historically, our specialty has been able to effectively design monitors and ventilation systems and to greatly reduce death due to hypoxia or ventilatory failure in anesthetized patients.
In their words, “safety should be funded because it is the right thing to do, not because of any ROI directives.” Commercial aviation and other similarly complex yet high-risk industries adopted a culture of safety years ago. The very practical solutions coming from this workshop, as well as the ASHP IV Medication Safety Summit may well provide the innovations in drug administration processes, as well as insight into the human factors responsible for inevitable human errors, which are needed to bring about a true reduction in medication errors in the operating room.
We take a systematic approach to visualize the future in the context of internal and external business environment, build organizational capacity for innovation and formulate strategies to overcome challenges and maximize future opportunities. The Joint Commission has made reduction of medical errors one of its national patient safety goals for the past several years. Therefore, elimination of medication errors represents a tremendous opportunity to save lives and improve patient care in the OR as well as in the remainder of the hospital. Anesthesiologists already have effective patient safety, “standards,” and “practice advisory” infrastructures in place. Comprehensive strategies are developed to continually improve quality of care, enable equitable and timely access to services, further enhance patient safety, introduce advanced technology and equipment, create value for patients and their families, and promote clinical, academic and research excellence.The key drivers of the DI Quality and Risk Management program include the Quality Assessment and Improvement Committee, DI and Image Guided Therapy (IGT) Morbidity and Mortality Review Rounds, MR Safety Committee, Equipment Quality Control Committee, Radiation Safety Committee, dedicated Quality Management Leader, and various project teams and work groups. If the diagram seems counter-intuitive, think of rapids in a river: as the river narrows, the water goes faster and the flow becomes more powerful. In 2006, the FDA mandated that manufacturers include a machine readable bar code on the label of the containers of many prescription drugs. Significant research has already been done to evaluate drug administration procedures and technology to improve safety of drug administration during anesthesia (Table 2).

Peer review process is integrated seamlessly into the daily workflow to ensure high level of competence amongst our radiologists, safeguard patient safety and improve overall standards by identifying unperceived discrepancies and educational needs. New technology such as bar codes, radio frequency identification (RFID), and computerized order entry (CPOE) systems have all come on the horizon as technological solutions, only to create different problems which may be almost as big as those they are intended to solve. Sins, MD, represented Partners Healthcare and brought unique expertise in the emerging “smart pump” technology.
All of these improvements have a potential to improve the process of drug administration in the operating room, which is a complex collection of more than 40 steps, if used to enable anesthesia providers to work more safely, as well as more quickly and efficiently.
The peer review process allows for the random selection of studies to be reviewed on a regularly scheduled basis, supports rapid identification of trends and reveals opportunities for quality improvements. Effective application of quality concepts, principles, and methods requires an inclusive, engaging, and empowering team environment, systems thinking, information sharing, interdepartmental collaboration, and decisive action based on systematically obtained evidence. Continually refined quality indicators used to measure, evaluate, and improve effectiveness of our processes are at the core of the DI Quality and Risk Management Program.
Every effort is made to enable sound decision making and promote evidence-based solutions by creating selective, reliable, responsive, valid, and cost-effective measures of performance.In order to adapt to a rapidly changing operating environment, align resources with key priorities, support hospital strategic directions, and ensure a coordinated approach to continual quality improvement, we have developed and implemented a customized, dynamic and integrated Quality Management System (QMS).
The QMS provides a framework for seamless integration of quality planning, quality assurance (QA), quality control (QC), process improvement, risk management, innovation, and a number of other structured, systemic and planned activities designed to improve quality and patient safety.
Therefore, we have developed a robust, data-driven and patient-focused process improvement framework to engage employees in a meaningful way, reduce process variation, improve flow, solve recurring problems, minimize wasteful activities, and create value from the viewpoint of patients and other stakeholders.
We strive to adapt, integrate and appropriately contextualize Lean, Six Sigma, Human Factors, Project Management, Plan-Do-Study-Act (PDSA) Cycle, and other complementary methodologies, disciplines, and best practices while taking into account specific goals, organizational culture and overall capabilities. The various process improvement methodologies are not mutually exclusive and they bring unique perspectives, approaches, tools, and techniques that can be effectively combined to achieve and sustain operational excellence. Rapid changes in imaging and information technology, increasing complexity of patient care, high cognitive demands, and large volume of information arising from research present unique challenges to radiologists, technologists, nurses, and administrative staff.
In response to these challenges, the discipline of Human Factors Engineering is applied to optimize system performance, reduce opportunities for errors, and design systems, processes, tasks, jobs, and work environment that take into consideration the needs and abilities of people. This tool was originally developed by the Institute for Healthcare Improvement (IHI) and Dr. The DI Quality and Safety Leadership Walkarounds are designed to foster an environment of trust by engaging leaders and front-line staff in an open dialogue concerning quality and patient safety, directly inform the leaders about existing organizational barriers, and demonstrate commitment to building a culture of safety, service excellence, innovation, and continuous quality improvement.

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