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By Mary Beth Navarra-Sirio, RN, MBA
Patient Safety Officer
McKesson Provider Technologies
The 1999 landmark Institute of Medicine report, To Err is Human, called attention to the nearly 100,000 people who die from medical errors every year. It also pointed to an obvious starting place for improvement: medication management. Hospitals quickly saw the power of technologies like bar-code scanning, pharmacy automation and CPOE in helping to prevent medication errors at each stage where they can occur.
Now there is a sense of urgency to eliminate preventable errors like never before — reinforced by every headline on a preventable mistake and each time another payor joins CMS in ceasing to reimburse for "never events." The time has come to take a more holistic view of patient safety because we won't stop all the errors until we change our approach. Safety is much more than just compliance — it's hardwiring safety into every process by using the power of technology and reinventing the culture of care.
Patient Safety — The Big Picture
What is the definition of patient safety? At McKesson, we believe it is: "The sustained, proactive process of identifying, avoiding and rapidly resolving errors, omissions and miscommunications that could affect patient health or safety, at any point, in any care setting." We also look at patient safety as a framework that spans the entire healthcare continuum.
 Medication safety covers the entire medication use process, from
the loading dock to the patient's bedside, including the prescribing,
transcribing, dispensing, administering and monitoring
of medications.
Diagnostic safety includes the gathering and interpretation of data
that supports accurate and timely diagnosis. Strategies to promote
evidence-based diagnosis are essential.
Treatment safety ensures the accurate capture, recording,
executing and sharing of data related to care delivery. Evidence-
based guidelines, treatment plans and clinical decision support
are essential, as is electronic capture of data as part of the
permanent patient record for all the care team to see.
Environmental safety ensures that the patient's surroundings are
safe, including the proper level and mix of staffing, taking steps
to avoid infection, following appropriate protocols, and having
needed supplies on hand.
Information safety refers to the availability of secure, up-to-date,
complete medical records for every patient. Cross-setting records
must be permanent, portable and trustworthy, with longitudinal
data on allergies, medication history and so on.
Communications safety includes the sharing of relevant, real-time
information to all authorized, interested parties, with particular
focus on the need to improve hand-off communications. According to
the Joint Commission, breakdowns in communication remain by far
the root cause of most sentinel events.
Cracking the Patient Safety Code
Healthcare has complex processes with many moving parts that affect and support patient safety. Making improvements means taking an incremental approach, making a change in one area and ensuring it is sustained before moving on. Some strategies include:
Gain buy-in from hospital leadership — To succeed, there
needs to be a mandate and a change in culture from the board of
directors down. Everyone's job is to make safety the first priority.
Start with areas of quick impact — Medication management
is a great place to start safety improvements. Automate the
medication process to prevent errors. After that, environmental
safety presents fertile ground for improvement.
View the big picture — Examine all of your processes, from
the dockside to the bedside. Are your medications bar-coded? Do
you have automated dispensing? Do your physicians use CPOE with
clinical decision support? Do you have a longitudinal,
cross-setting EHR?
Measure, adjust and reinforce — There is an old axiom —
"What gets measured gets done." Create dashboards that provide
information from the executive level to front-line caregivers.
Technology can empower you to check progress against patient
safety goals each day — from minute to minute or shift to shift.
Immediate feedback enables everyone to make
immediate adjustments.
Taking Care Safely Forward
As McKesson celebrates its 175th anniversary this year, it gives us reason to reflect on how healthcare has changed since we were founded in 1833. Our founders first delivered vital medications by covered wagon. We've created many innovations over the years, including the pioneering use of bar-code scanning of medications at the patient's bedside in 1988. Now millions of clinicians prevent millions of errors each year by simply scanning a bar code before administering a medication. We are committed to partnering with our customers to help them in their efforts to continue "taking care forward" and creating a culture of care that helps ensure safety for every patient.
Mary Beth Navarra-Sirio, RN, MBA, is McKesson's patient safety officer and develops patient safety strategies for McKesson products, lectures around the country and works with McKesson's Public Affairs department to educate policy makers on the importance of technology in improving patient safety.
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The American Hospital Association-McKesson Quest for Quality Prize was founded to honor and reward organization-wide commitment to quality, patient-centered care. The award uses the Institute of Medicine's (IOM) six quality aims as the foundation for the award: safety, patient-centeredness, effectiveness, efficiency, timeliness, and equity. Applicants demonstrate a systematic approach to achieving the IOM aims, documenting progress, and providing replicable models and systems for others to follow.
The award winner receives $75,000, and two finalists receive $12,500 each. Other hospitals may be recognized with Citations of Merit. All U.S. hospitals are eligible. You can nominate your own or another organization by completing a nomination form. An application packet will be e-mailed after receipt of the nomination. The 2008 awards will be announced in July. The deadline for submitting an application for 2009 is October 12, 2008. View the criteria for the award.
Quest for Quality is an American Hospital Association Award supported by grants from McKesson Corporation and the McKesson Foundation. |
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Safety Automatic
By Mary Beth Navarra-Sirio, RN, MBA
Patient Safety Officer
McKesson Provider Technologies
The 1999 landmark Institute of Medicine report, To Err is Human, called attention to the nearly 100,000 people who die from medical errors every year. It also pointed to an obvious starting place for improvement: medication management. Hospitals quickly saw the power of technologies like bar-code scanning, pharmacy automation and CPOE in helping to prevent medication errors at each stage where they can occur.
Now there is a sense of urgency to eliminate preventable errors like never before — reinforced by every headline on a preventable mistake and each time another payor joins CMS in ceasing to reimburse for "never events." The time has come to take a more holistic view of patient safety because we won't stop all the errors until we change our approach. Safety is much more than just compliance — it's hardwiring safety into every process by using the power of technology and reinventing the culture of care.
Patient Safety — The Big Picture
What is the definition of patient safety? At McKesson, we believe it is: "The sustained, proactive process of identifying, avoiding and rapidly resolving errors, omissions and miscommunications that could affect patient health or safety, at any point, in any care setting." We also look at patient safety as a framework that spans the entire healthcare continuum.
the loading dock to the patient's bedside, including the prescribing,
transcribing, dispensing, administering and monitoring
of medications.
that supports accurate and timely diagnosis. Strategies to promote
evidence-based diagnosis are essential.
executing and sharing of data related to care delivery. Evidence-
based guidelines, treatment plans and clinical decision support
are essential, as is electronic capture of data as part of the
permanent patient record for all the care team to see.
safe, including the proper level and mix of staffing, taking steps
to avoid infection, following appropriate protocols, and having
needed supplies on hand.
complete medical records for every patient. Cross-setting records
must be permanent, portable and trustworthy, with longitudinal
data on allergies, medication history and so on.
information to all authorized, interested parties, with particular
focus on the need to improve hand-off communications. According to
the Joint Commission, breakdowns in communication remain by far
the root cause of most sentinel events.
Cracking the Patient Safety Code
Healthcare has complex processes with many moving parts that affect and support patient safety. Making improvements means taking an incremental approach, making a change in one area and ensuring it is sustained before moving on. Some strategies include:
needs to be a mandate and a change in culture from the board of
directors down. Everyone's job is to make safety the first priority.
is a great place to start safety improvements. Automate the
medication process to prevent errors. After that, environmental
safety presents fertile ground for improvement.
the dockside to the bedside. Are your medications bar-coded? Do
you have automated dispensing? Do your physicians use CPOE with
clinical decision support? Do you have a longitudinal,
cross-setting EHR?
"What gets measured gets done." Create dashboards that provide
information from the executive level to front-line caregivers.
Technology can empower you to check progress against patient
safety goals each day — from minute to minute or shift to shift.
Immediate feedback enables everyone to make
immediate adjustments.
Taking Care Safely Forward
As McKesson celebrates its 175th anniversary this year, it gives us reason to reflect on how healthcare has changed since we were founded in 1833. Our founders first delivered vital medications by covered wagon. We've created many innovations over the years, including the pioneering use of bar-code scanning of medications at the patient's bedside in 1988. Now millions of clinicians prevent millions of errors each year by simply scanning a bar code before administering a medication. We are committed to partnering with our customers to help them in their efforts to continue "taking care forward" and creating a culture of care that helps ensure safety for every patient.
Mary Beth Navarra-Sirio, RN, MBA, is McKesson's patient safety officer and develops patient safety strategies for McKesson products, lectures around the country and works with McKesson's Public Affairs department to educate policy makers on the importance of technology in improving patient safety.
The award winner receives $75,000, and two finalists receive $12,500 each. Other hospitals may be recognized with Citations of Merit. All U.S. hospitals are eligible. You can nominate your own or another organization by completing a nomination form. An application packet will be e-mailed after receipt of the nomination. The 2008 awards will be announced in July. The deadline for submitting an application for 2009 is October 12, 2008. View the criteria for the award.
Quest for Quality is an American Hospital Association Award supported by grants from McKesson Corporation and the McKesson Foundation.
Medication Safety Advantage
Patient Care Advantage
McKesson Continuum of Care
Bar-Code Medication
Packaging Solutions
Instead of simply "fixing" problems using technology, Baptist Health reengineered their processes and invested in technologies that supported workflow.
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