Houston's University General Hospital Features Technologies That Prevent Medication Errors

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Also Included In: Medical Devices;  Medical Malpractice / Litigation
Article Date: 25 Feb 2008 - 4:00 PDT

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Houston's own University General Hospital places its commitment to patient safety at the forefront in making decisions regarding design and technology. Against the backdrop of a dramatic increase in the number of hospital medication errors in the last fifteen years, University General mitigates the risk of such events with an integrated medication management system. Medication errors have reached a rate of 1.5 million events per year, with a tripling of fatal cases between 1998 and 2005. A striking minority of US hospitals have invested in available safeguards that can prevent the kinds of medication dosing errors recently making the news. Late in 2006, for example, three infants died, and three others were harmed, by a massive overdose of the anticoagulant drug Heparin at a hospital in Indianapolis. More recently, two infant children of actor Dennis Quaid also received an adult dose of Heparin at a prominent hospital in Los Angeles. National incidents such as these are prominent enough that the Joint Commission, which accredits 85% of US hospitals, has made the safe use of anticoagulants one of its top national patient safety goals for 2008.

Recent news and related events are helping to raise public awareness about medication management technologies and methodologies currently available. These measures enable hospitals to track high-risk medications, calculate appropriate dosing based on individual patient variables such as age and weight, and dramatically reduce the risk of such incidents. In a November 26, 2007, article from the online magazine medpagetoday.com, discussing the recent outbreak of heparin overdoses in newborns, Dr. Lucian Leape, Professor of Health Policy at Harvard School of Public Health, is quoted as saying, "In 2007, hospitals really should be moving toward medication systems that are almost completely automated," which, he added, can eliminate up to 95% of errors. Though this figure represents a drastic reduction - but not elimination - of these incidents, it is clear that putting in place a technological safety net is an effective remedy.

Due to its streamlined and efficient design, University General Hospital is among the few hospitals that have invested in and fully implemented such a defense by putting into service Cardinal Health's Pyxis® technologies. This technology enables an interdisciplinary team of physicians, nurses, pharmacists, and others to perform a series of checks on medications as they make their way through the system. All medications are bar-coded, and the hospital maintains an internal database of the bar codes. When a physician orders a medication for a patient, a digital image of the order is transmitted to the pharmacist, who enters it into an order entry system equipped with protections against human error. When the order reaches the nurse on the medical floor, he or she must scan both the medicine and a bar-coded wristband on the patient for verification. The system imposes strict limits on overrides. With the system in place, University General Hospital achieved a 99.98% correct fill rate during calendar year 2007, with the miniscule number of errors being detected long before medications reached patients.

This system is supplemented by Cardinal Health's Alaris® IV pumps and Guardrails® software protection suite. These systems cross-check for possible IV medication issues, and include a respiratory module that constantly monitors patient-administered medications, interrupts their delivery, and alerts the nurses' station if the patient's respiratory activity drops below an acceptable level. In implementing these systems in the way that it did, the hospital went above and beyond the joint commission standards, to the extent that, during an inspection, a joint commission inspector remarked that the University General way should be the standard. Some of the other cutting-edge medical technology solutions University General has adopted include high-definition video equipment in the operating rooms, as well as voice-activated operating room equipment that surgeons can vocally maneuver. Investment in such systems is a part of University General's entrepreneurial and institutional vision of delivering optimized medical care to its patients through clinical excellence. A substantial emphasis on patient safety is a key pillar supporting this vision.

University General Hospital Systems
University General Hospital - Fannin Street