July 20, 2010
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UCSF Intervention Leads to Big Drop in Medication Errors

By Robin Hindery

Every year, medication errors in America’s hospitals kill thousands of patients and cost the country billions of dollars.

Despite those alarming figures, few research studies have focused on errors in medication administration, and previous interventions to address this problem have largely failed to improve accuracy.

That changed last year when a UCSF quality improvement program for nurses reported an 88 percent drop in medication errors over a 36-month period at six Bay Area hospitals.

Between September 2006 and September 2009, the Integrated Nurse Leadership Program (INLP) helped increase medication administration accuracy to 98 percent at the participating hospitals – up from 84 percent at the beginning of the intervention. The INLP is one of several leadership programs run by UCSF’s Center for the Health Professions.

One type of error that decreased significantly was related to distractions, such as overheard pages. Distraction-related mistakes dropped from 40 percent to 16 percent. Another type of error that decreased markedly was “wrong technique,” such as administering a drug with food when it should be taken on an empty stomach. Such wrong-technique incidents accounted for 46 percent of all errors when the intervention began, and dropped to 19 percent by the end of the three-year period.

Sustaining Successful Error Reduction

Julie Kliger, RN, who is director of the INLP, said the group is continuing to gather ongoing data with the hospitals to see whether they have sustained their error reduction. Early results indicate that after four years, hospitals are indeed maintaining their successes. “This is important because hospitals have a tough time sustaining improvement efforts after the formal activity has ended,” Kliger said.  “We can say that a year after the formal program ended, hospitals have integrated the improvement practices and cultural changes we had hoped to see.”

Julie Kliger (Photo by Patty Nason/Gavaphoto)

“These outcomes prove beyond any doubt that frontline clinicians are instrumental to improving the quality, safety and efficiency of American health care,” said Edward O’Neil, PhD, director of the Center for the Health Professions. “Frontline clinical workers have to be seen as a management resource, not a cost center. These are experienced, essential personnel who can identify problems, drive change and deliver results.”

The INLP aimed to train hospital clinicians – mainly nurses – to take a leadership role in developing new clinical protocols, reporting tools, metrics and administrative procedures. For the first 18 months, program administrators worked with two units in each hospital. The program was then expanded to the entire hospital for the remaining 18 months.

“It was a really interactive, experiential curriculum,” said Kliger. “The program not only helped participants develop the skills they need to make real improvements [in their workplace], but it also ignited that sense of responsibility and accountability that this is their work to do and they should step up to the plate.”

Improving Safety and Accuracy

Participants focused on six methods of improving safety and accuracy, including making sure medications were properly labeled, updating patients’ charts after each dose, and avoiding distractions and interruptions during the administration process.

Hospital nurses report that constant interruptions and high patient loads are the primary causes of medication administration errors. Such mistakes result in roughly 7,000 preventable deaths, 400,000 injuries and $3.5 billion in extra medical costs each year, according to the Institute of Medicine.

“Medication errors make up the largest piece of the medical-error pie,” Kliger said, “which makes sense because administering drugs is such a high-volume activity.”

At a hospital the size of UCSF Medical Center, clinicians administer approximately 250,000 to 300,000 medication doses each month, Kliger estimated. At the hospitals in the INLP study, nurses reported administering 55 to 88 medication doses each over the course of an eight-hour shift.

Tailored Solutions

The INLP intervention also allowed nurses at each hospital to develop and tailor their own solutions. At one location, for example, nurses successfully lobbied to replace the small, hard-to-read type on patient armbands with larger, more legible lettering.

The INLP yielded such positive results that its methods have already been duplicated by another California health system in three additional hospitals, Kliger said.

Kliger and her colleagues are currently working to apply the same framework to decrease the incidence of – and mortality from – sepsis, a life-threatening illness in which the bloodstream is overwhelmed by bacteria. Sepsis is a major cause of death in intensive care units worldwide.

Programs such as this bear directly on Chancellor Susan Desmond-Hellmann’s top priority – patients and health. And it demonstrates the value of accelerating the translation of research into improved patient care.

“Through this program, we are decreasing the time it takes for new research knowledge to become clinical practice,” said Kliger. “We are actually changing the way care is delivered so that patients receive the optimal care now, not years from now.”

The INLP was funded by a series of grants from the Gordon and Betty Moore Foundation through its Nursing Initiative, which seeks to improve nursing-related patient outcomes in adult acute care hospitals.