Disease Management Update
Volume IV, No. 37
January 10, 2008

Dear Healthcare Intelligence Network Client,

Each year, 11 to 15 of every 1,000 Americans visit a healthcare provider because of adverse drug events (ADEs). In dollars, ADEs are responsible for $2 billion per year in hospital costs nationwide, and measures as simple as improved care and reducing duplications of services can save healthcare organizations about $140 billion per year.

In this week's Disease Management Update, new technology from the University of Michigan Health System is preventing potential medication errors, while Vermont hospitals are taking financial responsibility for improving patient safety and eliminating adverse events in general.

Visit HIN's blog for some tips on preventing ADEs in older adults.

Your colleague in the business of healthcare,
Laura M. Greene
Editor, Disease Management Update

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Table of Contents

  1. Device Prevents Potential Errors in Children's Medications
  2. Disease Management Q&A: Using PHRs to Reduce ADEs
  3. HealthSounds Podcast: Persuing Perfect Care by Reducing ADEs
  4. Vermont Patients, Insurers Won't Pay for Adverse Events
  5. Survey of the Month: Medical Homes Use To Manage Chronic Conditions
  6. Improving IV Medication Safety

1. Device Prevents Potential Errors in Children's Medications

A device designed to eliminate mistakes made while mixing compounds at a hospital pharmacy was 100 percent accurate in identifying the proper formulations of seven intravenous drugs. Five potentially serious medication errors were averted over an 18-month period in a test at C.S. Mott Children's Hospital in the University of Michigan (U-M) Health System by using the technology, said Jim Stevenson, associate dean of Clinical Sciences at the U-M College of Pharmacy.

The hospital tested 40 to 50 samples daily, at strengths and at variations below and above the proper dosage amount. The process takes about a minute, so the technology could be integrated into the workflow of the pharmacy when used for select high risk products. Stevenson said the hospital is the first in the world to use this device to test patient drugs compounded in the pharmacy. The U-M Health System already has many safeguards, such as bar coding, in place to avert mistakes.

“Our goal needs to be to have zero tolerance for errors," Stevenson said. "If we wanted to eliminate errors completely we knew we couldn't continue to rely completely on human visual checking. We needed to implement some sort of technological solution to overlay our human process for these drugs to be failsafe."

To learn more about this study, please visit:

2. Disease Management Q&A: Using PHRs to Reduce ADEs

Each week, healthcare professionals respond to a reader's query on an industry issue. This week's experts is Dr. Bruce Taffel, chief medical officer and senior medical director of health informatics for Shared Health.

Question: What percentage of members access personal health records (PHRs)?

Response: (Dr. Bruce Taffel) The PHR is a burgeoning concept. Our initial efforts were geared more to the provider side because we saw a greater potential for ROI in their utilization.

We thought it would reduce markedly ADEs and treatment duplications if physicians could see drug-drug interactions,readily available lab reports and magnetic resonance imaging (MRI), results. We figured there would be an immediate payoff so that’s where we started.

Like many health plans, we have a member portal through which members can access benefits and plan information. We’ve seen high access here. The PHR is a developing field and the research has been interesting. Experiments with commercially available PHRs have not demonstrated much success to date. This may be because the records are not linked directly to the physician. We’re trying to merge the two.

For more answers to a variety of healthcare questions, please visit:

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3. HealthSounds Podcast: Pursuing Perfect Care by Reducing ADEs

Lenore Blank, Michelle Gilbert, Donna Isgett and Leanne Huminski describe how their organizations are implementing perfect care processes in heart failure and medication management with details on how they've implemented their programs and the results they are achieving. Huminski, chief nursing officer, McLeod Regional Medical Center, comments on capitalizing on computer technology, McLeod's initiatives for eliminating adverse drug events (ADEs) and the role information technology is playing in reducing ADEs.

To listen to this complimentary HIN podcast, please visit:

4. Vermont Patients, Insurers Won't Pay for Adverse Events

Vermont Governor Jim Douglas and the Vermont Association of Hospitals and Health Systems (VAHHS) announced that all Vermont hospitals will adopt a uniform policy to not seek payment from patients or insurers for hospital care resulting in certain rare but serious adverse events as defined by the National Quality Forum (NQF). Vermont is only the third state in the nation to take this voluntary step, and hospitals expect the policy will be in place by fall of 2008.

The policy will cover eight very rare but serious events and is based on nationally accepted definitions. The hospital association and the governor have selected these events because they are serious, preventable, caused harm and events over which hospitals have some control. The list includes surgery on wrong body part, air embolism-associated injury, surgery on wrong patient, medication error injury, wrong surgical procedure, artificial insemination/wrong donor, retention of foreign object and incompatible blood-associated injury.

“Patient safety is our top priority, and partnering with the governor to create this policy sends a strong message that hospitals are very focused on preventing medical errors,” said VAHHS President Bea Grause. “This initiative is just another step in our long-term strategy to make Vermont hospitals the safest in the country. The primary goal here is to improve patient safety.”

To see more of this survey's results, please visit:

5. Survey of the Month: Medical Homes Use To Manage Chronic Conditions

Complete our survey on medical homes use by January 31, and you'll get a free executive summary of the compiled results.

To participate in this survey and receive its results, please visit:

6. Improving IV Medication Safety

Of all the medication errors, intravenous (IV) infusion errors, which involve high-risk medications delivered directly into a patient's bloodstream, have the greatest potential for patient harm. IV medications have been associated with up to 54 percent of potential adverse drug events (ADEs), 56 percent of medication errors, and almost 61 percent of the serious and life-threatening potential ADEs. A nurse would never give 100 pills to a patient intended to receive only one; however, he or she can inadvertently misprogram a general-purpose infusion device and deliver such a massive overdose.

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