National Patient Safety Goals

Dekalb Regional Healthcare(DRH) System has a number of policies based on

National Patient Safety Goals. This has been a primary focus of CMS during their
surveys recently, which has driven compliance with these goals. Among these are
Adverse Drug and Medication Error Reporting, Computerized Prescriber Order Entry,
Weight Based Heparin Protocols, Medication Reconciliation, and High Alert
Medications.
Medication Error(MedError) Reporting and Adverse Drug Reporting (ADR)
have come to the forefront recently. Both of these are considered Adverse Drug
Events(ADEs). The distinguishing factor between ADRs and MedErrors is
preventability. If an event is unanticipated or not preventable, it is likely classified
as an ADR. However if it is an event that could have been prevented, it is likely
classified as a MedError. An example of a MedError is giving a patient penicillin
when they have a known allergy to penicillin. However, if there was no past history
of penicillin allergy and the patient received penicillin and had a reaction to it, this is
not preventable and classified as an ADR. At DRH there are a number of methods
for reporting. First among these is voluntary reporting. This method relies on the
providers to report any ADEs themselves. This is commonly the only method
utilized in an institution. It is a low cost, low maintenance form of reporting and will
give you decent qualitative information. However there is often underreporting of
ADEs and this seems to be commonly accompanied by a punitive culture. There
have been many efforts made recently to reduce the punitive nature of ADE self
reporting to encourage more reporting.
Another form of ADE reporting is through software the tracks trigger/tracer
drugs. These drugs are ones that often are often associated with ADEs. Examples
could include kayexalate (which is used in a potassium overdose), protamine (often

National Patient Safety Goals

used in heparin over dosages), Narcan (used in opioid overdoses), Dextrose 50%
injection (used in insulin overdoses) or phytonadione (Vitamin K, which is used in
Coumadin Overdoses). These trigger drugs provide much more data, however you
tend to get the same things reported time and again. Therefore you get more
quantity but less quality out of the reporting.
A third type of ADE reporting is Direct Observation. This involves someone
following a nurse around and watching what happens. This is an expensive and
time consuming process. It compares what DOES happen to what SHOULD happen.
This method is not as commonly used because of the costs and its labor-intensive
nature.
These are only some of the ways DRH has worked to meet national patient
safety goals. The CPOE system has improved accuracy and efficiency in order
processing from physician to pharmacy, hopefully reducing ADEs and improving
quality of care. Medication Reconciliation has provided a way to make sure that
medications are reviewed at every transition in care a patient undergoes. This
includes admission, transfer from unit to unit, and discharge. By making sure the
medication therapies ordered are continued properly (or discontinued properly)
outcomes have improved for patients.
In conclusion, Dekalb Regional Healthcare System has followed the
recommendations of the accrediting bodies and worked diligently to improve patient
safety in a number of ways, from Error reporting to improved technology and better
guidelines for physicians and nurses.