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NPSF Lucian Leape Institute 'Must Do' List

Posted By Administration, Friday, August 21, 2015

Writing for the NPSF Lucian Leape Institute, Dr. Bob Wachter authored an article on the Health Affairs blog calling for greater accountability among clinicians for certain practices that have been shown to increase the safety of care and improve outcomes.


Dr. Wachter and the Institute members believe, he wrote "it is time to require that clinicians follow certain well-established safety practices." Calling it the beginning of a "Must Do" list, Dr. Wachter cited hand hygiene and influenza vaccination of health care workers as "two evidence-based, relatively inexpensive, and highly effective practices."


The post acknowledges the importance of a Just Culture in health care and the -- usually -- appropriate emphasis on systems as a cause of error or adverse events. Yet willful disregard for established policies, the Institute members believe, can no longer be ignored.


Dr. Wachter specified the criteria to be considered for an action or practice to be added to the 'Must Do' list:

  1. The patient safety problem that is being addressed is important.
  2. The practice has been demonstrated by research or expert consensus to be effective in reducing harm.
  3. The impact of compliance with the practice is substantial, i.e., a significant number of patient harms would be prevented.
  4. Universal compliance with the practice, and auditing such compliance, is feasible for clinicians, health care organizations, and accreditors.
  5. The practice has been accepted as a standard by the National Quality Forum, relevant specialty societies, and by broad professional consensus.

Read the full article on the Health Affairs website.

What would you add to the 'Must Do' List? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

Tags:  Leape  med errors  Wachter 

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Game-Changing Guidelines: RCA2

Posted By Administration, Thursday, July 23, 2015

More than 7,000 listeners tuned in to our webcast on improving root cause analyses—a clear indication that health professionals and organizations want help with their RCA process.



By Patricia McTiernan, MS


Root cause analyses have been used in health care for a long time, but the success of these investigations has been variable across organizations and the industry. As discussed at a July 15 webcast hosted by NPSF there has been a lack of standardization in the process, failure to identify systems-level causes, and, too many times, the solutions put in place after the event are not strong enough to fix the problem that caused it. On top of that, it is not unusual for busy health professionals to fail in following up to make sure the solutions they put in place are working as intended.


More than 7,000 listeners tuned in to the webcast, RCA2: Improving Root Cause Analyses and Actions to Prevent Harm, which provided an overview of the report of the same name that NPSF released in June. The high number of attendees for this session is a clear indication that health professionals and organizations want help with their RCA process.


  Jim Bagian, MD, PE
  Doug Bonacum, CSP, CPPS  
Speakers Jim Bagian, MD, PE, and Doug Bonacum, CSP, CPPS, NPSF board members who led the panel that drafted the new guidelines, began with an explanation of the report’s name. “RCA squared” refers to the fact that there are two As: root cause analyses and actions.


Root cause analysis, said Bagian, is a misnomer, because seldom is there only one root cause. Moreover, analysis does not solve anything by itself; more important is the fact that actions need to be taken to prevent future harm.


So what do the guidelines recommend? First of all, Bagian pointed out that RCA2 was put together to provide much-needed standardization and a road map for how to conduct a successful RCA that would result in effective and sustainable action that would prevent future harm to patients. The report received endorsement by a number of organizations from across the country in recognition of its value in enabling users to achieve greater impact for improving patient safety.


The purpose of an RCA2 is to find out what happened, why it happened, and what you are going to do to prevent it from happening in the future.


Bonacum summarized what he called the game-changers of this report:

  1. Use a risk-based prioritization scheme to determine what warrants an RCA2. A risk-based approach includes weighing the severity and likelihood of an event along with the actual or potential harm is poses. Risk-based prioritization allows examination of close calls, which can be a harbinger of an event.
  2. Involve patients and families. Those directly involved in the event should be interviewed to share their perspectives of what happened, but they should not be a part of the RCA2 team. The RCA2 team should include a patient/family representative—for example, a member of the hospital’s Patient and Family Advisory Council.
  3. Use an action hierarchy. The actions taken in the wake of an event and an RCA2 are the most important component, because strong actions will prevent the event from recurring. Warnings and increased training, for example, have historically been shown to be relatively weak in preventing a recurrence, while actions such as forcing functions or a simplified process that removes unnecessary steps is more likely to yield success.
  4. Involve the organization’s leadership and board. For the process to be successful, Bonacum said, it is critical that it be embraced at all levels of the organization, including the CEO and board of directors. This would involve, for example, the allocation of resources to conduct RCAs, but also the CEO’s review and approval of all actions recommended by the RCA2 team. Actions that are not approved should be documented so that the team knows why and can create another action that will be accepted. The report includes warning signs of an ineffective RCA, to help CEOs in their review.

NPSF thanks The Doctors Company Foundation for support of the production of the report and webcast. If you have not had a chance to read the report—or listen to the webcast replay—visit the web page.


Do you think the RCA2 guidelines will help improve root cause analysis in your organization? Comment on this post below (NOTE: you must be registered and logged in to this website to comment.)




James P. Bagian, MD, PE, is the director of the Center for Health Engineering and Patient Safety at the University of Michigan.

Doug Bonacum, CSP, CPPS, is vice president for Quality, Safety, and Resource Management at Kaiser Permanente.



Tags:  med errors  RCA  root cause analysis 

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Intercepting Drug Name Confusion Errors

Posted By Administration, Monday, April 27, 2015
Updated: Monday, April 27, 2015

Researchers recently presented evidence to suggest that drug name confusion may be more common than previously thought, but that use of alerts in computerized prescriber order entry systems may help prevent them.

By Patricia McTiernan, MS

The Centers for Education and Research on Therapeutics (CERT) program, sponsored by the Agency for Healthcare Research and Quality, aims to increase drug knowledge and awareness, provide clinical information to patients and medical practitioners, and improve the quality of patient care while simultaneously cutting costs. Tools for Optimizing Medication Safety (TOP-MEDS) is the theme of one of only seven CERTs nationwide, and its researchers are working on four main projects that focus on different aspects of medication safety.

In one of the most recent phases of their work, the TOP-MEDs researchers presented evidence to suggest that drug name confusion may be more common than previously thought, but that use of alerts in computerized prescriber order entry systems (CPOE) may help prevent such errors. This article summarizes their most recent findings.


Background on Drug Name Confusion

Bruce L. Lambert, PhD, principal investigator of the TOP-MEDS CERT, says prior research indicates that wrong-drug errors occur at the rate of about 1 per 1,000 prescriptions in both the inpatient and ambulatory settings. Drug name confusion—a subset of wrong-drug error—is when a clinician confuses the names of two drugs that sound alike or look alike in text.


According to Dr. Lambert, drug name confusion is thought to be the most common type of wrong-drug error, and it can be costly and devastating. For example, Fosamax (a bisphosphonate used to treat osteoporosis) can easily be confused with Flomax (an alpha blocker most commonly used to treat benign prostatic hyperplasia). Hydroxyzine (often used as a sedative) can be confused with hydralazine (a vasodilator used to treat high blood pressure).


As Dr. Lambert points out, there are few effective methods to counteract wrong-drug errors at the point of prescribing. Tall-man lettering (the use of capital letters to distinguish the unique part of the name) has produced mixed results in experiments. Bar coding can be effective at finding wrong-drug errors, but to maximize its benefit it needs to be used at every stage of the drug use process.


The TOP-MEDs team created a clinical decision support (CDS) structure by combining information about drug names, drug indications, and diagnoses in the CPOE system. They tested it in the University of Illinois Hospital and Health Sciences System, in both inpatient and clinic settings. Previous phases had shown that indication alerts can intercept wrong-patient errors (i.e., creating an order in the wrong chart). The more recent phase looked at wrong-drug errors, resulting in intercepting errors at a rate of 1.4 drug name confusion errors per 1,000 alerts.

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Background on the CDS System

Maintaining accurate problem lists in electronic medical records is required by The Joint Commission and is a requirement for meaningful use of health IT as defined by the federal government. Previous research by the TOP-MEDs team used the problem list to identify wrong-patient drug errors.


William Galanter, MD, PhD, MS, medical director of the TOP-MEDs CERT, associate chief health information officer at University of Illinois Hospital and Health System, and a practicing internist, led the development of a list of indications for a subset of drugs in the system’s formulary. The drugs chosen were those that had a relatively small number of indications (for example, metformin, beta blockers, SSRIs). Alerts were set to go off if a physician ordered a drug with an indication that did not match a problem in the patient’s problem list. The physician could then either 1) add the problem to the problem list; 2) change the order; or 3) override the alert.


The team examined more than 125,000 alerts that occurred over a six-year period. According to Dr. Galanter, they determined that an error had been intercepted if the following conditions were met: an alert triggered; the initial medication order was not completed; and the same prescriber ordered a similar-sounding medication for the same patient within five minutes. Similarity of drug names was based on standard measures, and two clinicians performed chart review to determine whether the first, uncompleted order had a plausible indication for use.


The results showed 1.4 drug name confusion errors were intercepted per 1,000 alerts. “From the literature, we had a sense that the rate of wrong drug errors was 1 in 1,000 orders, so I was hoping that if we had a robust intervention, we might see half of that or a quarter of that,” says Dr. Galanter.


As he and Dr. Lambert point out, their team examined only instances where alerts occurred, so they cannot say for certain what the overall error rate is. The alerts were set to go off only for the list of drugs for which indications has been identified. Theoretically, many more drug-name confusion errors may have gone undetected. Still, these latest results support implementing clinical decision support in CPOE to prevent wrong-drug errors, just as previous research showed alerts can also prevent wrong-patient errors and that they can help clinicians populate the problem list.


“What these results show is the potential power of trying to connect indications, diagnoses, and medications in the electronic medical record,” said Dr. Galanter. “Trying to look at those three pieces of information is probably a very fruitful area for future research.”


This research was published in the July 2014 issue of PLOS One. View the study paper online at

Does your organization use the electronic medical record to flag potential drug-name confusion errors? Comment on this post below.

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Patricia McTiernan is editor of the P.S. Blog. Contact her at

Tags:  CPOE  decision support  med errors  problem list 

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