The Joint Commission, the Institute for Healthcare Improvement, and other organizations have identified medication errors and the points of transition during patients’ care that increase their likelihood as promising targets in the push to improve quality outcomes. Communication, coordination of care, and the effective application of health IT hold the key to reducing errors and improving patient safety. 

 that medication errors continue to be one of the most frequent causes of preventable harm in healthcare. 

 at transition points in patient care is responsible for as many as 50% of all medication errors and up to 20% of adverse drug events in the hospital setting. The Joint Commission also notes that its 

 (accurately and completely reconciling medications across the continuum of care) has been exceptionally difficult to score since its introduction in 2005. Because of this difficulty in scoring, as of January 1, 2009, findings will be evaluated during the on-site survey; but, “given the difficulties many organizations are having in meeting the complex requirements of this goal, they will not be factored into the organization’s accreditation report.” This difficulty in scoring makes it all the more necessary to have electronic systems and other technologies in place to meet and exceed expectations not only for when the Joint Commission comes to visit, but also for the betterment of our patients. 

Technology solutions to medication errors continue to evolve on a number of fronts, including simplified dispensing, direct order entry, PCA pumps that are programmed to be both patient- and drug-specific, and even experimentation with “polypills,” capsules that may contain up to seven drugs (all in low doses) for a variety of adult maladies. The Institute for Healthcare Improvement has been a leader in promoting advanced medication reconciliation at all transfer points, having identified early on that medication errors are one of the leading causes of injury to hospital patients. 

 reveal that more than half of all hospital medication errors occur at the interface of care. As I see it, IT solutions hold the greatest promise to eliminate these errors, with programming that will focus on care transitions and any discrepancies or disruptions in medication management. 

It is across the continuum of care that the reconciliation process has its greatest impact. According to the 

, “transitional care is defined as a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location.” These locations and their transfers include hospitals, subacute and postacute nursing facilities, the patient’s home, the office practice (both primary and specialty), and longterm care or assisted living facilities. As we begin to evaluate the quality and safety of each movement and point of handoff, we see that proper management of medications and medication lists will fall under the rubric of medication reconciliation. 

The integrated medical record has great potential to put all of this information “on one page”--or at least to have it reside in only one location. Even when care is provided across multiple sites and services (as is often the case), only one medication record need exist. It can be used to prescribe, populate clinical notes, handle admission orders and refills, and be included in discharge summaries. At a minimum, required fields include drug name, dosage, frequency, and route. The record system we use at the Mayo Clinic also requires amount and date of last refill, and it does an exquisite job of identifying drug—drug interactions. With our system, all providers who are addressing medication needs can access the electronic record at each site of service and update the medication list in real time. The medication history can also be brought up to discover when a drug was discontinued, and perhaps why (there is a voluntary field of entry for this information at my institution). 

As we pursue a patient-centered approach to care, the medical record and the individual it refl ects should be able to travel together. Moreover, medication lists are becoming available to patients, home care providers, and families as medical practices make patient-specific information available on the Internet. 

In 2008, the AMA’s Physician Quality Reporting Initiative (PQRI) allowed 119 measures that were published in the 

 to be used for reporting and additional reimbursement. Of those, 117 were clinical performance measures and two were structural measures that focused on either the use of an EHR or e-prescribing technology. The savvy practice will utilize its EHR to not only report clinical performance, but also to advance the care and safety of each patient and be rewarded along the way. 

With the transition of care measures at various stages of development both at PQRI and at the National Quality Forum, medication reconciliation is the keystone for measure development. The current focus is on hospital discharges and how well the handoff goes. One way to judge is how well the medications were reconciled--what was omitted, what failed to restart following transfer or discharge, what has been duplicated, and what dose or dosages are incorrect. The next frontier, subject to the same analysis, will be how well nursing homes and home health agencies pass or receive the baton of responsibility. It behooves all of us to work as quickly as possible to integrate hospital and outpatient records along with pharmacy records in order to eliminate errors of duplication, omission, and transcription. 

I believe that we can only take quality measures so far. Although the science of qualitative measurement continues to advance, much still remains in the eye of the beholder. Medication errors, on the other hand, are quantitative and can be approached with methodical measurements toward Six Sigma. In the elimination of duplicate steps, we have less opportunity for error and also save time and money. Again, a unified record can give us the opportunity to keep track of who prescribed what, as well as when and even for what reason. 

I know of no fully integrated programs that can follow patients across more than two or three sites of service. Nonetheless, progress is being made across the country as we explore the opportunities provided by the EHR. At Mayo, we have adopted a master medication list that is used by all outpatient primary and subspecialty practices. It is available to our two teaching hospitals and is also available to staff who are attending to patients in our local nursing homes. It is not yet integrated with pharmacies at any location other than Mayo for e-prescribing, nor does it populate the hospital or the nursing home record. However, it is a step in the right direction and has put far more physicians on the same page. 

This integration also allows for instant review by the patient at every encounter. If adjustments are made, they are only made once and are stored in only one location. The medication list is maintained in its own repository and then loaded to the next clinical encounter. Institutions moving along these lines will be better able to follow patients across all transitions of care with a singular health record that recognizes only one medication list. 

editorial board member, and a professor of medicine and co-director of the Robert & Arlene Kogod Program on Aging at the Mayo Clinic in Rochester, MN

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Feature Articles

The Joint Commission on Accreditation of Healthcare Organizations
states that medication errors continue to be one of the most frequent causes of preventable harm in healthcare. As Tangalos sees it, electronic and IT solutions hold the greatest promise to eliminate these errors.

First, Do No Harm: The Role of Medication Reconciliation in Reducing Preventable Errors

Electronic health records (EHR) have been in the national spotlight recently due to the fi nancial incentives included in the American Recovery and Reinvestment Act (ARRA), designed to entice hospitals and physician practices to transition from paper-based record systems to EHRs. However, a recent study found that less than 2% of acute care hospitals have a comprehensive EHR system currently in place, and more than 90% of US hospitals do not even meet the requirement for a basic EHR.

 Some hospitals, however, have been quick to recognize the benefi ts of EHRs and have already taken steps to prepare for a paperless future. 

Anticipating the potential improvements in the delivery of safe and effective patient care, the Children’s Hospital of Pittsburgh (CHP) began the gradual transition to an EHR in 2002. I am a pediatric hospitalist with the Paul C. Gaffney Diagnostic Referral Service (DRS) at CHP and have been able to personally participate in this amazing transition process. The DRS cares for more than 95% of all general pediatric admissions to the hospital. Therefore, our group played an important consultative role in developing and guiding the EHR implementation process. 

When I began working at CHP in July 2005, the transition to a completely paperless system was already underway. CHP began to modernize in 2002 with the installation of a computerized provider order entry (CPOE) system and an electronic medication administration record (MAR), which also incorporated lab results and radiologic images. However, documentation was still done by hand. There were two paper charts: one at the bedside for nursing documentation and one in the work area for physician and ancillary staff documentation. At least that is where the charts were supposed to be found! The cry of “Has anyone seen my patient’s chart?” could be heard resonating at each patient care station several times per day. The charts seemed to have the remarkable ability to disappear at the most inopportune times. Even if the chart could be found, there were inevitable battles over access and control among the various medical services charged with providing care to the patient. 

CHP began the transition to a truly paperless documentation system by fi rst moving all nursing documentation (ie, signifi cant clinical events, intake and output, vital signs, patient measurements) to the EHR. The next step was requiring the physicians to document their initial history and physical examination notes (H&Ps) in the EHR. This process began with the pediatric residents in November 2007 and then slowly incorporated the pediatric attendings and surgical teams. By January 2009, all H&Ps and daily progress notes were on the EHR, and paper charts could no longer be found on the wards. On May 2, 2009, when CHP moved to its new 1.5 million-square-foot campus, patients and equipment were transported to the new location, but paper chart racks were left behind. 

The path to a paperless hospital was far from smooth; our staff had to overcome several signifi cant challenges during the transition to an EHR, not the least of which was providing an adequate number of computers for the providers so they could document electronically. This was made even more diffi cult by the fact that our old hospital building had severe layout and space restrictions. Thankfully, it is no longer an issue at the new location. Currently, CHP has more than 4,000 computers for use by our staff, with more than 400 miles of cabling and nearly 1,800 wireless access points to provide 100% network coverage throughout the hospital. The CHP patient care wards have large nursing and physician work areas with numerous computers available, enabling clinicians to complete their documentation without having to fight over who gets to use the computers. Additionally, several of the workstations are “computers-on-wheels” (COWs)--mobile units that can be easily shifted from one location to another. They can be brought into the work areas if more computers are needed, or wheeled to the patients’ bedsides for medical rounds. 

One of the most significant benefits of the EHR for providers has been the dramatic increase in information accessibility. Gone are the days of searching high and low to find a patient’s paper chart. Now, I can access a patient’s chart from any computer in the hospital. Consider that a patient admitted to CHP today will be cared for by an average of 70 clinicians who will view the patient’s EHR more than 500 times over the course of a five-or-six-day hospitalization. Each day, 10 separate authors will enter nearly 20 notes into the patient’s electronic chart. When you consider our entire patient census, that means nearly 45,000 computerized notes are created each month. Given this tremendous demand for access to each patient’s chart, it is not difficult to see the benefits of adopting an EHR. 

CHP has been conducting family-centered rounds (FCRs) since 2008. The EHR plays an integral role during the daily FCR process. During FCRs, team members will need access to the patient’s admissions record, lab results, radiologic findings, and other specific information. Therefore, the team will often bring two or three COWs with them to the patient’s bedside. This point-of-care access to specific and accurate information greatly facilitates the team’s ability to make appropriate patient management decisions. Essentially, ready access to the EHR eliminates the guesswork—Is this truly the most up-to-date information we have for this patient? What is missing from this chart?&mdash;associated with paper records. Now, daily patient notes can be created by a team member during FCRs so that accurate assessments and plans are documented. The team member can quickly pull objective data such as vital signs, labs, and radiologic readings directly into the note, which helps to prevent transcription errors. 

I am certain that the access to patient information provided by the EHR has improved the fl ow of my work day. I see my patients during FCRs and discuss the plan with the residents and nurses, and with the patient and his or her family. Before our hospital implemented an EHR, I would have to go through the laborious process of fi nding the patient’s chart and then try to write my note quickly (and legibly) before someone else needed the chart. Now, I can return to the comfort of my own offi ce, log on to the EHR, and input my documentation or insert an addendum to the resident note that was already created. Distractions and interruptions are at a minimum in my offi ce, allowing me to spend less time inputting documentation. With our system, I also have the option to securely log on to the EHR from any computer with Internet access anywhere in the world. Therefore, if I have an off-campus meeting, I can enter my daily notes into the system from my laptop or using any computer, wherever I may be. 

When children are transferred from another institution or come from their primary care physician’s offi ce, all of their paper documentation is placed into a folder to be scanned into CHP’s EHR. Within 24 hours, all of the outside hospital’s documentation can be accessed through CHP’s EHR, and the paper documentation can be appropriately discarded. This means that normal labs and x-rays are not unnecessarily repeated; they are easily found from the prior records, just a mouse click away. 

Another major advantage to using an EHR is that it greatly enhances patient safety. Handwritten orders and documentation can be diffi cult to read correctly, which can lead to signifi cant medical errors. An estimated 44,000-98,000 deaths occur annually due to medical errors.

 It is suspected that 200,000 adverse drug events each year could be prevented by moving to a CPOE system.

 Since the implementation of the CPOE system in 2002 at CHP we have seen a 60% decrease in medication safety events. The move to a completely paperless EHR will presumably continue to decrease these preventable adverse events. At CHP, we also electronically scan a barcode on the patients’ ID band and a barcode on the package of any medication that is to be given to the patient. This ensures the administration of the correct drug, at the correct dose, by the correct route, to the correct patient, at the correct time. Additionally, the scanned bar code system enables accurate recording of these parameters automatically into the MAR. CHP has been recognized by healthcare informatics leaders such as HIMSS Analytics (www.himssanalytics.org), The Leapfrog Group (www.leapfroggroup.org), and KLAS research (www.klasresearch.com) for effectively implementing an EHR and improving patient safety. 

It has been a tremendous experience to participate in CHP’s shift to an EHR. While there have been some diffi cult steps during the process, it has overall been a remarkable transition. The information technology group at CHP has been tremendous; it would not have been possible to successfully implement an EHR without the support they have provided to the clinicians and other staff. Due to the EHR, the delivery of patient care has been revolutionized and patient safety has been dramatically improved. It is an exciting time to be in medicine, with technology pointing the way toward an even brighter future. 

Kishore Vellody, MD, is an assistant professor of pediatrics at University of Pittsburgh School of Medicine and a member of the Diagnostic Referral Service at Children’s Hospital of Pittsburgh, where he is also the director of the Evening Hospitalist Program.

1. Jha A, DesRoches C, Campbell E, et al. Use of Electronic Health Records in U.S. Hospitals. 

To Err Is Human: Building a Safer Health System

2. Kohn L, Corrigan J, Donaldson M, eds. 

. Washington, DC: National Academy Press; 1999. 

3. Hillestad R, Bigelow J, Bower A, et al. Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefi ts, Savings, and Costs. 

Surveys show that more than 90% of US hospitals do not use even a basic EHR, despite the improvements to efficiency, care coordination, and patient safety to be gained by implementing an EHR. Some hospitals, however, have been quick to recognize the benefits of EHRs, and have already taken steps to prepare for a paperless future.

The End of the Paper Trail: One Pediatric Hospital's Experience with the Transition to a Fully Electronic Health Record

What are the advantages of having dedicated nocturnists instead of rotating doctors? 

As hospital medicine continues to evolve and grow as a specialty, hospitalist groups are looking to branch out and provide more services. A variety of factors are prompting hospitals to expand coverage to provide 24/7 hospitalist care, leading to the creation of a new sub-specialty: the nocturnist. Although many programs, in an effort to recruit nocturnists, promise shorter hours, more fl exible scheduling, and better pay, the lifestyle adjustment nighttime coverage requires is not for everyone. To fi nd out more about the pros and cons of choosing this career path and lifestyle,

 spoke with Ravi Santhanam, MD, an IPC hospitalist who practices as a nocturnist at Methodist Hospital in San Antonio, TX. Dr. Santhanam currently serves on the hospital’s Medical Executive Committee and Medical Records Committee. 

Well, for one thing, it keeps the daytime doctors refreshed, so they can have a better night’s sleep. It’s more of a regular work schedule, so they can focus better on their daytime duties, and at night, they can take care of the admissions and the emergencies at night, which is what they are meant to do.

Have you seen any statistics or studies that show improvements to patient care when nocturnists are hired in a hospital setting? 

I don’t think we can connect any studies that have been done, right off the top of my head, because it’s a new thing, a new concept. 

What would you say are the benefi ts to being a nocturnist? Is there a downside to working as a nocturnist?

Well, the biggest benefit is obviously more free time, because most nocturnists get a week on, and then a week off, which gives you enough time to catch up with your family and personal life, and most nocturnist jobs are two weeks a month. Another benefi t to being a nocturnist is that they usually receive a higher base pay than regular hospitalists, and they get the whole benefi ts [package]. Sometimes they have a bonus package, but it depends on how many patients they see. 

Obviously, the detriment is that you’re working against the body clock, because you have to get used to the shift work. Another drawback is that you don’t get to follow the patients during the day. Sometimes, you’d like to know a little more about what’s happening with them. You work with them, and you take care of them, and then another person comes in and takes over in the morning. 

Is it difficult to find and recruit doctors who are willing to take on this role? 

It has been a bit hard, because most people are not familiar with the concept of a nocturnist, but I think once they’ve done it for a cycle, some doctors find it easier than the daytime shift. 

What do you like best about the nocturnist position, and are there any things that you particularly don’t like about the idea?

Generally, if you’re a nocturnist, you can become less involved in the hospital’s activities, such as meetings and committees, and you don’t want to let that happen. At night, it’s just you and the patient and maybe one or two relatives over the course of the night. It’s pure medicine. You do a lot of procedures, you can handle emergencies, but mostly you’re really on your own. 

Is that the most challenging part of the job? 

Yes. if you’re the only doctor in the hospital that night, if something happens, you’re the fi rst point of call. You will be responsible for making sure all of the patients in the hospital are taken care of. I think it’s a lot more hands-on medicine, and obviously there are a lot of other concerns, because at night, it’s pretty much you. For the right hospitalist who is familiar with doing procedures and doesn’t mind being on his or her own, it’s a good job to start with, if you want to be right in the center of the action.

To date, there is very little evidence in the literature showing that round-the-clock hospitalist coverage using nocturnists produces better outcomes than programs that rely on on-call physicians. An article in a 2008 issue of the 

 newsletter quoted Kenneth Epstein, MD, MBA, director of medical affairs and clinical research at IPC The Hospitalist Company, Inc, as saying there is little difference between these two approaches in terms of outcomes. According to the newsletter, Epstein studied more than 80 IPC hospitalist programs (programs that provided 24/7 coverage and those that used on-call physicians) and compared them across an array of quality outcomes (length of stay, readmission, mortality, etc), fi nding “no measurable advantage to 24/7 programs.” These fi ndings were originally presented in an abstract at the 2007 Society of Hospital Medicine annual conference. The newsletter noted that Epstein is “currently concluding his research in a retrospective analysis article to be published in 2009.” 

A Day (or Night) in the Life of a Nocturnist 

…Ahh, I get to carry the [general internal medicine] pager. I wonder how many pages I am going to get tonight asking if I cover [General Internal Medicine Triage Offi cer] patients. Do they not realize those two little letters mean so much? (buzz buzz buzz) The fi rst barrage of pages, and of course all the teams have signed out by 5:15pm. This patient is agitated, in restraints, and no haldol prn? The patient got switched to percocet at 3:00pm and already wants their dilaudid? A family meeting now? (buzz) First admission from the Emergency Department (ED). Nice to see they are cleaning house. Time to go to the ED. (buzz buzz) Do I know if the patient will go home tomorrow? Maybe, though I will not decide. Yes, the patient can have an extra dose of dilaudid and benadryl. Why is she not on a patientcontrolled analgesia (PCA) pump? Need to transfer her to GIM 3. Well, done admitting that 90 year old for altered mental status and a history of metastatic pancreatic cancer on tube feeds and severe dementia. The only person I could contact was her granddaughter who fi rmly believes the patient would want everything done... ok… 

I’ve got some time to review cross-coverage sign out. Let’s see only 7 subspecialties notes to review, 6 BMPs, 5 chest… x… rays. 4 hemoglobins, 3 cardiac enzymes, 2 line placements, and a restraint order to be signed at 4:00am. (Using the tune from the Twelve Days of Christmas) 

(buzz) You called an AMET on chest pain? Are the vitals stable… yes? Ok, I guess. I will be right there. Stat EKG, enzymes, CXR, and nitro. The patient is fi ne after the nitro? Let us see how the enzymes turn out… 

The midnight hour approaches. 2 hours later, oh there are the stat cardiac enzymes which are negative. Should I go to the call room now, or wait for my next admission? Admitting and Kaiser still are waiting. (buzz) Am I Orange? Not since last year. Also, why does the GIM pager always get paged when Orange is asked for? No, I do not cover Kaiser. No, I do not distribute admissions, call the GIMTO. 

Let us see, it is 1:30am. I wonder if I will get 3 hours of sleep. (buzz) Another patient who can not sleep? Why do they not put ambien in the water? (sleep… buzz) Yes, did someone page GIM? General Internal Medicine? (hold) No one paged me? Ok… did anyone page anyone? Yes… yes, you can give an extra dose of dilaudid…

Want to read more about the role of the nocturnist? Check out these resources for more information: 

		How to Find and Keep Dedicated Nocturnists 

www.the-hospitalist.org/details/article/188669/Duty_after_Dark.html 

		Physicians of the Night: The Who, What, and Why of Nocturnists 

www.acphospitalist.org/archives/2008/12/cover.htm

		Hospitals Move to Reduce the Risk of Night Shift 

http://online.wsj.com/article/SB121193074899024387.html

As hospital medicine continues to evolve and grow as a specialty, hospitalist groups are looking to branch out and provide more services. 

October 2009

First, Do No Harm: The Role of Medication Reconciliation in Reducing Preventable Errors

The End of the Paper Trail: One Pediatric Hospital's Experience with the Transition to a Fully Electronic Health Record

Nocturnists: The Night Owls of the Medical World

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