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The leading cause of death in the US is heart disease, but more than 250,000 deaths each year are caused by medical error, it emerged. The views expressed in the contents above are those of our users and do not necessarily reflect the views of MailOnline. The Occupational Safety and Health Administration recorded nearly 4,000 worker fatalities in 2013. Even the most careful and experienced team of construction workers can’t prevent every accident. Fall protection, including guardrails, toe-boards, safety harnesses, and other protective equipment, is required on many jobs. If you’ve suffered the unspeakable loss of a family member due to a construction accident, no one can put a price on your loss. As NHTSA and the nation's Emergency Medical Services (EMS) family celebrate the first thirty years of organized EMS and prepare for the many challenges of appropriately serving our communities into the Twenty First Century, our continuing goal is to reduce unnecessary death and disability. Our continuing partnership with the Health Resources and Services Administration, Maternal and Child Health Bureau, provided us with the opportunity to take an important step in pursuit of this expanded goal, through the development of the "Leadership Guide to Quality Improvement for Emergency Medical Services Systems". Quality is anything that enhances the product or services from the viewpoint of the customer (patient).
With the rapidly changing health care environment, EMS must determine how it can best serve community health, while remaining the public's emergency medical safety net. The Leadership Guide is presented in a loose-leaf format to allow for addition of new materials and notes resulting from continued study and growth in the area of quality improvement.
NHTSA plans to develop additional materials and programs to contribute to continued growth in this important area and we would strongly encourage EMS leaders at all levels to embark on this journey with us. Jason Paluck, Emergency Health Services Department, University of Maryland-Baltimore County, Baltimore, Maryland.
Since the enactment of the National Highway Safety Act of 1966, and the formal beginning of emergency medical services (EMS), the common goal of EMS systems has been to reduce unnecessary death and disability.
This manual provides a useful guide for EMS system leaders to use to improve quality within their organizations. Leadership involves efforts by senior leadership and management leading by example to integrate quality improvement into the strategic planning process and throughout the entire organization and to promote quality values and QI techniques in work practices. Human Resource Development and Management involves working to develop the full potential of the EMS workforce. EMS System Results entails assessing the quality results achieved and examining the organization's success at achieving quality improvement. Satisfaction of Patients and Other Stakeholders involves ensuring ongoing satisfaction by those internal and external to the EMS system with the services provided. Experience from other fields shows that integrating QI into an organization or system takes several years.
Your EMS organization or system will begin its QI journey when the leaders begin the process of learning about the theory, techniques and benefits of quality improvement.
Stage II establishes the structural foundation necessary to fully integrate QI into the strategic planning process. As you look at each of the Baldrige categories and their implications for structural and procedural changes in your EMS organization, keep in mind a very important concept: the most important results for achievement are improved health of EMS patients, improved quality of EMS services, and improved efficiency of resource use.
The remainder of this manual covers the application of each of the seven Baldrige categories to EMS. Everyone working in EMS can find ways to promote quality and efficiency, to improve all aspects of the EMS system, and to promote excellence and personal accountability. EMS managers, reviewing ambulance response performance over time, discover that the goal of on-scene arrival within 6 minutes after notification only happens about 20% of the time.
Quality can be built into all EMS activities and services and can be assured by continuous examination to identify potential improvements. Leaders create the opportunity for workers to suggest improvements and act quickly to make needed changes in production process. The Japanese have a saying: "Every defect is a treasure", meaning that errors and failures are opportunities for improvement. Improved performance cannot occur unless workers feel comfortable that they can speak truthfully and are confident that their suggestions will be taken seriously. Barriers between organizations or between departments within one organization are obstacles to effective QI. Eliminate slogans, exhortations, and targets for the workforce for zero defects and new levels of productivity. The problem with such exhortations is that they put the burden for quality on worker performance instead of poor system design.
For Deming, work production standards and rates, tied to incentive pay, are inappropriate because they burn out the workforce in the long run. EMS workers can improve their lives through education and ever-broadening career and life opportunities. Juran also developed the idea of instituting a leadership group or "Quality Council", consisting of the organization's senior executive staff. Quality Improvement - creation of special teams to plan, test, and implement new methods to reach unprecedented levels of performance. The QI principles and methods of Deming, Juran and Crosby provide a basic foundation for most QI efforts. The Emergency Medical Service (EMS) leader's role in promoting and developing QI begins with creating and sustaining a personal and an organizational focus on the needs of internal and external customers and consumers. EMS leaders must insure that all organizational and system processes focus on the needs of patients and other stakeholders.
Operational goals and objectives are defined within the strategic quality planning process and provide day-to-day direction for system progress.
People perform better and strive harder to succeed when they feel personally invested in their work. Through careful planning and transition, managers can maintain authority and responsibility while, at the same time, increase the autonomy of and input from staff. Senior EMS leadership must also create opportunities for managers to develop and improve their management skills within the context of the QI effort. Managers should also be encouraged and supported in their efforts to demonstrate to the entire organization their ongoing commitment to quality improvement. All members of the EMS leadership system should assess how well they each "walk the talk" of quality improvement. EMS organizations are part of the communities they serve and can contribute to community well-being in the same sense that every citizen is expected to contribute. The efficient collection and management of data and its transformation into useful information are fundamental to a successful Quality Improvement program. Standardization of data refers to the organization's efforts to make uniform its data sets, data definitions, codes, classifications, and terminology across departments and services, as well as to make them compatible with external data bases.
Timely data provides accurate, up-to-date information about the performance level of key processes in the EMS agency or system. Define the EMS Data Set: Define the minimum data set needed to accommodate the evaluation of key performance areas. Specify Requirements for Registry Participation: Define data collection and submission requirements - including checks for data quality, completeness and timeliness - format of data submission, and operational definitions. Provide Registry Software: Software that meets reporting requirements is vital for successful data collection and analysis. Support Statewide Programs in Data Quality: Ensuring the integrity of data and data collection procedures is a fundamental component of an EMS data and information system. Determine the Contents of Data Analysis Reports: The content and frequency of data analysis reports determine how and how well data will be used in QI activities. Planning: Planning for all the various data management activities is crucial at the local level, since it is here that most of the data is collected.
Procedures for collecting and recording data should be specific, well-defined, and reflect an understanding and appreciation for the working environment of the providers who collect the data.
Check Data: Registry software should perform checks for data quality and require that data anomalies be resolved and records "closed" before they are reported on or transferred to an intermediate or statewide database. Data Quality Program: Data quality and timeliness are key to the success of the QI program, and provider training is a significant determinant of data quality. Statewide Level: By virtue of its statewide perspective, the state EMS Office can be particularly useful in evaluating the effectiveness of data management. Understanding customers and markets: EMS serves entire communities and populations-at-risk.
What other technologies may potentially compete with EMS system components (e.g., telephone advice systems, interactive TV, Internet searching and information exchange as a substitute for 911)? Strategic quality planning is neither magical nor mysterious; it is simply an organized method of determining where an EMS system or organization wants to be and how it plans to get there. EMS systems involve many different organizations and individuals with separate authorities, management, and governing bodies, each of which may have its own strategic quality planning process. The activities of each level of EMS (state, regional and local EMS organization) are different, but complimentary. Strategic quality planning at the state EMS level differs from strategic planning at the local or agency level. The state EMS strategic quality plan serves as the roadmap for achieving quality improvement in EMS for the entire state. A vision statement provides a futuristic look at and broad guidance for the EMS agency or system. While development of the vision statement is directed by the leaders of the state, regional, or local EMS system, the system or agency "players" should be deeply involved in the development process.


Typically, a vision statement would be a short, motivational description of the EMS system's ideal condition.
Emergency Medical Services of the future is a community-based health management system that is fully integrated with the overall health care system. EMS represents the intersection of public safety, public health, and medical care systems.
As one component of a varied and complex health care system, EMS will be significantly impacted by the continuing evolution of health care. New research suggests that electronic medication management may be the only effective way to reduce medication error. Electronic medication management (eMM) is gathering momentum in the United Kingdom with hospitals increasingly seeing e-prescribing as an essential tool. The trend is likely to continue with a growing body of evidence indicating the effectiveness of electronic medication management.
In the drive toward electronic medical records (EMR), trusts in the UK are prioritising how they manage medications and share this information with other hospital systems – they are doing this by implementing ePMA systems such as MedChart. Around the same time, a second NHS Foundation Trust in the north of England completed a rigorous clinical engagement programme to evaluate suitability of MedChart for the acute NHS environment. In December 2011 a third trust announced progress toward a full-end-to-end electronic patient record, with roll-out of MedChart medication management. A similar scenario is playing out in Australia and New Zealand where some hospitals began using MedChart in the early 2000’s.
In late 2010, under the auspices of the NZ National eMedicines Program, Dunedin Hospital on New Zealand’s South Island, conducted a successful MedChart pilot. These reports were analyzed to classify the events by node, related processes, possible causes, and contributing factors and to detect trends and noteworthy cases. However, inadequate fall protection has been the most frequently cited safety violation in recent years. Sometimes the equipment has design flaws; other times, people have failed to maintain or repair it properly.
What makes the situation even worse is that funeral expenses and lost wages will take an additional toll on your family.
Department of Transportation, National Highway Traffic Safety Administration, in the interest of information exchange.
Since quality improvement is based on management by fact, information and analyses are critical to QI success.
Within the context of quality improvement, process management refers to the improvement of work activities and work flow across functional or department boundaries.
High quality organizations tend to think of their suppliers as "partners" in their operation.
This requires close cooperation between those who provide services and those who consume services. The role of the state EMS leadership is to meet the needs of regional leaders who in turn meet the needs of local agencies. Personnel who focus on data quality can also provide ongoing data-related training and independently abstract run data to check the accuracy and reliability of field data and data collection procedures. Providers need a thorough understanding of all operational definitions, the applications and importance of data, those activities necessary to ensure data completeness and quality, and prescribed procedures for data collection. Strategic quality planning is not something separate from the EMS system; rather, it is an integral, ongoing part of the system. Strategic quality planning, as well as the entire QI process itself, should occur at the local, regional, and state EMS system level. Hospitals in the UK, Australia and New Zealand are implementing systems that improve their ability to manage medications. Evidence of this trend is demonstrated by plans for a fifth NHS trust to implement CSC MedChart, known in the UK as ePMA. One such example is new research from Professor Johanna Westbrook of the University of New South Wales. Following the successful pilot, work commenced on implementing e-prescribing across numerous specialities at the hospital trust’s four main hospitals, including accident and emergency, medical assessment unit and, oncology and surgical wards, under plans for a trust-wide implementation. Ultimately, the new system will provide integrated management of stock control and dispensing. The electronic medication management software will be integrated with the trust’s existing IT infrastructure including patient administration system (PAS), laboratory and eDischarge systems to facilitate the timely and accurate sharing of medicines related information within the trust and with general practitioners. Safety rules such as those set forth by OSHA are a good start; employers are required to adhere to OSHA’s safety standards and to educate their workers in on-the-job safety.
What that really means is that contractors and property owners could do more to prevent falls on the job, particularly when we consider that falls account for more construction accident deaths than any other cause. The researchers found significant decreases in medication error when e-prescribing systems were used. Vincent’s Hospital Sydney was one of the earliest adopters and has been using the system since 2004.
Funding has recently been provided to roll MedChart out to another 120 beds by the end of June and plans are afoot for a regional roll-out across the Southern District Health Board. Anti-infectives, opioids, and anticoagulants were the most common types of medications associated with wrong-patient events. If even half of the “fatal four” accidents were prevented, 238 American workers’ lives could be saved each year. Macquarie University Hospital implemented MedChart in 2010 and the following year, the Little Company of Mary Health Care (LCM) group implemented the system at a first site.
This has led to a national initiative to have electronic prescribing in every public hospital in New Zealand by the end of 2014. While multiple factors may have contributed to each event, the most common were two patients being prescribed the same medication, improper verification of patient identification, and similar room numbers.
While specific activities may differ depending on the jurisdiction of the organization, the developmental stages of QI integration will be the same for local, regional, or statewide EMS organizations. The vision statement is unique to that service and is consistent with the local system and state vision statements.
Wards using MedChart experienced a 57.5 percent reduction in prescribing errors, harmful errors were reduced by an impressive 44 percent. Important risk reduction strategies include ensuring proper storage of medications and patient-specific documents, utilizing healthcare technology fully, limiting verbal orders, and improving patient verification throughout the medication-use process.Introduction Patient misidentification has been a long-standing problem that has permeated all aspects of healthcare and led to errors ranging from wrong-site surgeries to discharging infants to the wrong families to ordering incompatible blood.
These groups provide an excellent forum for the development of leadership expertise and consensus on regional and statewide quality improvement direction and policy.
All fields of the event reports, including harm score and care area, were self-reported, but the medication name fields were adjusted during analysis if information on the medication involved in the error had been available in the event description. Various trends were quantified using descriptive statistics.Aggregate AnalysisDuring the aforementioned reporting period, the Authority received 826 distinct medication error event reports from Pennsylvania healthcare facilities that were categorized as wrong-patient events. However, based on the event descriptions, 13 reports (1.6% of total reports) did not actually involve wrong-patient errors and were excluded from the analysis. The remaining 813 reports represent errors that occurred across the continuum of the medication-use process (from prescribing to administration and monitoring of medications), involved a wide range of medications, and occurred on various patient care units and departments.The errors reported occurred during all nodes of the medication-use process (see Figure). Almost 13% (n = 104) of reports listed anti-infective medications as being involved in the event.
Of the reports involving a known single medication, almost 30% (n = 169) were associated with high-alert medications. The third most common care area noted in the reports was the emergency department (9.8%, n = 80).
It is unclear, however, whether the locations noted in the event reports represent where the errors originated or where the errors were discovered.Despite the variety of medication errors involving the wrong patient, few resulted in patient harm. Medication procurement consists of a nurse obtaining the wrong medication from various medication storage areas (see Table 1). For example, multiple reports described a nurse selecting the wrong patient from the automated dispensing cabinet (ADC) screen when retrieving medications.
Monitoring is defined as patient assessment activities that occur before or after administration of medications.
Medication Storage Areas Involved in Events Occurring  during the Medication Procurement Process, as Reported to the  Pennsylvania Patient Safety Authority, July 2011 to December 2011Many factors, and often more than one factor per event, contributed to patients receiving other patients’ medications during actual medication administration. Most commonly, two patients were prescribed the same medication, and one received the medication dose intended for the other (14.3%, n = 41).
The second most prevalent contributing factor was inadequate identification (ID) check (12.9%, n = 37), in which the event descriptions specifically mention failure to use two patient identifiers and to confirm identity with patient ID bracelets. In four reports (1.4%), the nurse used the patient’s or family’s acknowledgment of the name, which was incorrect, to verify identity. The nurse either confused the patient with a roommate or administered the medication to the wrong patient due to similar room numbers. The nurse did not check the patient’s [ID] bracelet, and the patient received another patient’s morning medications.The patient was in the hall, and the nurse called the name of a patient.
The patient responded “Yes.” The nurse looked at a picture and then asked the patient where her wristband was since it was not on the patient.
The patient responded, “I took it off a couple days ago.” The nurse looked at the patient’s picture and asked again, “Are you this patient?” The patient responded “Yes” and took the medications without questioning them. Later, the nurse realized that the two patients look very much alike.The nurse attempted to administer [a medication]. The nurse asked three adults in the room to verify the patient, since the patient was a pediatric patient and no ID bracelet was on. All three verified and allowed the nurse to give the medication to the patient when it was the wrong patient.The wrong patient profile was viewed on the screen.


The nurse pulled Vicodin® for pain for a patient in 123A but was on the patient in 123B medication profile. The scan matched and at this point, the nurse did not notice that he was on the wrong profile. The nurse approached 123A, scanned [the patient’s] bracelet, and administered the medication without checking the screen to see if the correct patient was scanned.Wrong-Patient Errors during TranscribingThe second most prevalent node in which errors originated was transcribing. Transcribing was defined as the process that involves the transferring of a paper medication order to a patient’s electronic or paper MAR. Nurses, pharmacists, unit clerks, and others can perform this task; however, few of the reports identify the personnel involved.
Of the transcribing events, most errors were due to transferring orders into the wrong chart (81.4%, n = 253). Various contributing factors were identified, but none were associated with more than 4.1% (n = 4) of reports. In one report, a physician gave a verbal order for a medication but did not use the patient’s full name. The pharmacist was notified, who reported that the cardiologist called asking for a “stat” amiodarone for a patient but only gave the patient’s last name. It was later discovered that the patient was in the registration area but not yet admitted.
The doctor had indicated that it was an urgent situation.The doctor came to see the patient, while the nurse was in the room, and discussed the medications he was going to order.
However, since the patient is in the same room with his wife, the doctor spoke to both of them. When the doctor told the husband what medications he was going to write, he also told them to the nurse and went to the desk to write orders. While looking over the copy of the orders, the nurse noticed they were written on an order sheet with the patient’s wife’s ID sticker on it.
The nurse went to the wife’s chart and saw that the doctor had written the orders in the wrong chart. A filling error is made when a medication prescribed for one patient is dispensed from the pharmacy for a different patient. When I called the pharmacy to inquire about it, the pharmacy said they had no recall of them sending the Levaquin for 465, but they said they did recall that it was sent for 456. A pharmacist who was on the unit was approached by nursing about the delivery of the Fioricet, as it was not in the patient's drawer. The nurse happened to look in the medication drawer of another patient and discovered the Fioricet.Contributing Factors Associated with Wrong-Patient ErrorsBesides those mentioned above, several contributing factors that span the medication-use process were identified. Although the proportions were low, these characteristics were present in events that may have been prevented with system changes (see Table 2).  Table 2.
Contributing Factors and Characteristics of Wrong-Patient Errors,  as Reported to the Pennsylvania Patient Safety Authority,  July 2011 to December 2011.In roughly 6% (n = 52) of the events, reporters mentioned that one patient was confused with another because both patients were to receive the same medication.
While most of the errors occurred during administration, four errors (7.7%) originated during prescribing. In another example, a nurse confused intravenous (IV) medication bags for two of his patients who were on the same medication. Since I was all the way in the back hall, I removed both vancomycin [bags] from the fridge at the nursing station.
ISMP has recommended that verbal orders be limited to use during emergencies and similar situations.12 The following example typifies a verbal order that was transcribed onto the wrong patient’s chart.
Later, another patient was complaining of itching, and the nurse received a report that an order was obtained. The low prevalence may be because many hospitals may already have mechanisms in place to prevent confusion between patients with similar names. In fact, the assumption that similar names are the cause of most wrong-patient errors may result in other failure points being ignored.
The example below mentions that two patients had the same first letter of their last names, but this was likely not the only reason for the incorrect transcription.An order for Imodium® 2 mg as needed was entered for the wrong patient on the same floor. The order was sent to the pharmacy two more times after the original was entered on the wrong patient. In one example, the confusion involved a discharged patient who had previously occupied the same bed. Two other examples described insulin pens of discharged patients being dispensed or used on current patients.
Even documents from discharged patients were mistaken for those of current patients.During the morning assessment, it was noticed that the previously infused antibiotic syringe on the IV pole with another patient’s name on the medication label was connected to current patient. The name and date of birth were on the label for a discharged patient, from the previous day, [who had occupied the] same room and bed.The patient in this room was ordered a heparin drip based on an ECG [electrocardiogram] strip on the chart that showed a rhythm of atrial fibrillation. The ECG strip that was on the chart did not belong to this patient but was from the patient who had been in the room yesterday but had been discharged.
The heparin drip was ordered this morning by the cardiology resident, and the error was found this afternoon during cardiology rounds by the cardiologist. The patient never received any heparin, and the order was discontinued as soon as it was discovered by the cardiologist.Finally, some reports described events in which patients or their family members caught wrong-patient errors.
Below is an example that illustrates one such case.I was called to the patient’s room by the wife who noted, within 10 minutes of initiation of infusion, that the IV pump read vancomycin but the medication bag was labeled as acyclovir and with a different patient’s name.
Dose immediately discontinued and no reaction noted.Risk Reduction StrategiesThe reports of wrong-patient events submitted to the Authority reveal the complex nature of wrong-patient medication errors (see Table 3). While often thought to occur only during administration, these types of errors were identified in all phases of the medication-use process. Descriptions of How Wrong-Patient Medication Errors Occur,    by Node, as Reported to the Pennsylvania Patient Safety Authority,  July 2011 to December 2011     Improve Patient Verification for All Patient EncountersWhile the Joint Commission has an NPSG of improving the accuracy of patient identification, the proper use of two patient identifiers may still not be performed at all times.13,14 Such verification should be considered for all patient-associated tasks, including prescribing, reporting of test results, and communication of medication information between providers. Several reports illustrate examples whereby patients with similar room numbers or the same drug were prescribed, dispensed, or administered a dose intended for another patient. Overreliance on patient location and the name of the medication ordered may have contributed to one event reported to the Authority about a pharmacy technician dispensing an insulin pen with the label of a previous patient located in the same bed attached to it. In fact, the Joint Commission’s NPSG requires healthcare practitioners to use at least two patient identifiers (not the patient’s room number or location) when providing care, treatment, and services. If used, clearly label these bins and design them to facilitate medication delivery and retrieval. Moreover, some of the reports describe patients receiving the wrong medication because doses intended for other patients were placed in the former patients’ rooms.Similarly, store and return patient-specific documents in the patient’s chart.
For example, a misplaced monitoring sheet may result in an unnecessary treatment for another patient.
Standardizing the labeling practices for paper documents, monitoring sheets, and lab results can decrease the risk of wrong-patient errors.Lastly, institute procedures to remove medications and documents from active patient care areas when patients are discharged.
Bar coding during medication administration can be a reliable double check if performed correctly. Some of the reports analyzed in this study stated that bar coding successfully detected the wrong-patient error; however, a number of reports indicated that improper use of scanning prevented the error from being caught. In these instances, nurses administered the medication first then scanned the patient’s armband second, or nurses failed to check for a confirmation from the scanning prior to administration. ISMP has received many reports similar to the latter example and has described this problem in its newsletters.19Hospitals often use ADCs as secure storage units for medications without fully using system capabilities to prevent errors. An ADC that allows nurses to override a majority of medications essentially eliminates a pharmacist’s double check of the prescriber’s order. Standardize policies that detail when verbal orders are appropriate, who may receive verbal orders, how to give and receive these orders, and the safety checks that should be used to prevent error. In an earlier example, the prescriber failed to provide appropriate identification and the pharmacist failed to confirm the patient’s identity by reading back patient identifiers in the chart. They noticed IV bags with labels that had another patient’s name, and in one event described earlier, a family member even noticed the medication mismatch on the IV bag and the IV pump.Establish patient education programs to teach patients the importance of accurate patient identification during all points of contact and how staff should be verifying their identities. For example, if the facility uses bar-code identification, encourage the patient to speak up if his armband is not scanned prior to medication administration.
To accomplish this, some organizations have implemented programs in which patients and family members become active partners in ensuring patient safety. These programs include brief safety orientations for the patient upon admission, dedicated hotlines, and educational material listing questions that the patient should be asking the healthcare practitioners who care for them.ConclusionWrong-patient medication errors can occur at any phase of the medication-use process. While events reported to the Authority suggest that these errors occurred most often during administration and transcription, implementing safety strategies at all nodes can help to ensure that the correct patient receives the correct medication.AcknowledgmentsMichael J. Gaunt, PharmD, Pennsylvania Patient Safety Authority, contributed to manuscript preparation.NotesNational Patient Safety Agency. He thought the “lady in the door” was the “lady in the window”: a qualitative study of patient identification practices.
Understanding and preventing wrong-patient electronic orders: a randomized controlled trial [online].
The use of patient pictures and verification screens to reduce computerized provider order entry errors.
The physician taking care of Patient A asked the nurse to order vancomycin for that patient. The nurse had the electronic charts for both Patient A and Patient B open and accidentally entered the medication on Patient B’s chart.
The pharmacist verifying the order received a duplicate-medication alert from the computer system and realized that Patient B had already been started on vancomycin two days earlier.



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