Are verbal orders a threat to patient safety?

BACKGROUND: The use of verbal orders has been identified as a potential contributor to poor quality and less safe care. As a result, many organisations have encouraged changing the verbal orders process and/or reducing/eliminating verbal orders altogether (Joint Commission (2005), Institute of Medicine (2001), Leapfrog organisation, Institute of Safe Medication Practices). Ironically there is a paucity of research evidence to support the widespread concern over verbal order. AIMS: This paper describes the very limited existing research on verbal orders, presents a model of verbal order use identifying potential error trigger points and suggests a verbal order research agenda in order to better understand the nature and extent of the potential patient care safety threat posed by verbal orders.

Are verbal orders a threat to patient safety?

BACKGROUND: The use of verbal orders has been identified as a potential contributor to poor quality and less safe care. As a result, many organisations have encouraged changing the verbal orders process and/or reducing/eliminating verbal orders altogether (Joint Commission (2005), Institute of Medicine (2001), Leapfrog organisation, Institute of Safe Medication Practices). Ironically there is a paucity of research evidence to support the widespread concern over verbal order. AIMS: This paper describes the very limited existing research on verbal orders, presents a model of verbal order use identifying potential error trigger points and suggests a verbal order research agenda in order to better understand the nature and extent of the potential patient care safety threat posed by verbal orders.

An exploratory study measuring verbal order content and context.

BACKGROUND: The use of verbal orders, while essential in some healthcare settings, has been identified as a potential contributor to poor quality and less safe care. Despite the widespread use of verbal orders, little research attention has been paid to understanding and measuring the content of verbal orders or variables related to the context in which verbal orders are made. AIM: This paper first identifies variables related to verbal order content and context, and then provides detailed analyses from two exploratory studies conducted in one community hospital. METHODS: The data presented were collected using both a paper-based manual audit, and an analysis of data generated from a computerised order entry system. DISCUSSION: Selected analyses focus of variations in types and timing of verbal orders hospital-wide as well as for specific inpatient units, changes in verbal order utilisation following implementation of a computerised provider order entry system, and an analysis of the presence of sound-alike and high-alert medications in verbal orders.

Organizational culture, continuous quality improvement, and medication administration error reporting.

This study explores the relationships among measures of nurses' perceptions of organizational culture, continuous quality improvement (CQI) implementation, and medication administration error (MAE) reporting. Hospital-based nurses were surveyed using measures of organizational culture and CQI implementation. These data were combined with previously collected data on perceptions of MAE reporting. A group-oriented culture had a significant positive correlation with CQI implementation, whereas hierarchical and rational culture types were negatively correlated with CQI implementation. Higher barriers to reporting MAE were associated with lower perceived reporting rates. A group-oriented culture and a greater extent of CQI implementation were positively (but not significantly) associated with the estimated overall percentage of MAEs reported. We conclude that health care organizations have implemented CQI programs, yet barriers remain relative to MAE reporting. There is a need to assess the reliability, validity, and completeness of key quality assessment and risk management data.

Pediatric tele-echocardiography: evaluation of transmission modalities.

Pediatric cardiology consultation has been effectively delivered outside the tertiary care setting through the use of tele-echocardiography. This study examined the effectiveness of several tele-echocardiography connections and the satisfaction of the referring physicians using these services. Studies were transmitted via either a shared fiber-optic (DS3) connection (two sites), a dedicated fast-copper (ISDN-PRI) link, or by courier from a nearby (25-mile) or distant (170-mile) site. Time intervals between when echocardiograms were performed locally until they were received, interpreted, and reported were prospectively recorded. Referring physician satisfaction was assessed through a survey. The critical time between when a remote echocardiogram was performed and when its result was reported to the referring physician was primarily determined by the mode of transmission. The time interval between performing an echocardiogram and receiving the study was significantly longer for echocardiograms sent from the 170-mile courier site (2474 +/- 295 min) than either the 25-mile courier site (474 +/- 151 min), DS3 (374 +/- 121 min), or ISDN-PRI (129 +/- 16 min). Regardless of the method of transmission, all referring physicians felt that the service improved their ability to manage children, and they would recommend the service to their colleagues. Those using the courier service from the 25-mile away site were more concerned about the availability of a pediatric cardiologist and image quality, presumably due to the delay in response times. The time interval data provided in this study and the assessment of physician satisfaction provide important data as echocardiography laboratories implement tele-echocardiography services.

Improving medication administration error reporting systems. Why do errors occur?

Monitoring medication administration errors (MAE) is often included as part of the hospital's risk management program. While observation of actual medication administration is the most accurate way to identify errors, hospitals typically rely on voluntary incident reporting processes. Although incident reporting systems are more economical than other methods of error detection, incident reporting can also be a time-consuming process depending on the complexity or "user-friendliness" of the reporting system. Accurate incident reporting systems are also dependent on the ability of the practitioner to: 1) recognize an error has actually occurred; 2) believe the error is significant enough to warrant reporting; and 3) overcome the embarrassment of having committed a MAE and the fear of punishment for reporting a mistake (either one's own or another's mistake).

Tele-education in a telemedicine environment: implications for rural health care and academic medical centers.

Over 50 million people in the United States (about 20% of the population) live in rural areas, but only 9% of the nation's physicians practice in rural communities. It is difficult to recruit and retain rural health care practitioners, partly because of issues relating to professional isolation. New and enhanced telecommunications links between community and academic hospitals show promise for reducing this isolation and enhancing lifelong learning opportunities for rural health care providers. This paper will explore some of the issues involved in using interactive video (telemedicine) networks to transmit continuing medical education programming from an academic center to multiple rural hospitals. Data from a recent University of Iowa survey of the state's health educators will be presented as one approach to assessing the health care marketplace for the deployment of tele-education services.

Understanding and comparing differences in reported medication administration error rates.

The prevention of medication administration errors (MAEs) represents a central focus of hospitals' quality improvement and risk management initiatives. Because the identification and reporting of MAEs is a nonautomated and voluntary process, it is essential to understand the extent to which errors may not be reported. This study reports the results of 2 multihospital surveys in which over 1300 staff nurses in each survey estimated the extent to which various types of nonintravenous (non-i.v.) and intravenous (i.v.)-related MAEs are actually being reported on their nursing units. Overall, respondents estimated that about 60% of MAEs are actually being reported. Considerable differences in estimated rates of MAE reporting were found between staff and supervisors working on the same patient care units. A simulation based on actual and perceived rates of MAE reporting is presented to estimate the range of errors not being reported. Implications regarding the reliability, validity, and completeness of MAEs actually being reported are discussed.

Understanding why medication administration errors may not be reported.

Because the identification and reporting of medication administration errors (MAE) is a nonautomated and voluntary process, it is important to understand potential barriers to MAE reporting. This paper describes and analyzes a survey instrument designed to assist in evaluating the relative importance of 15 different potential MAE-reporting barriers. Based on the responses of over 1300 nurses and a confirmatory LISREL analysis, the 15 potential barriers are combined into 4 subscales: Disagreement Over Error, Reporting Effort, Fear, and Administrative Response. The psychometric properties of this instrument and descriptive profiles are presented. Specific suggestions for enhancing MAE reporting are discussed.

A performance comparison of communication links between rural hospitals and a digital health sciences library.

BACKGROUND: Rural physicians need access to digital health sciences libraries (DHSLs) that is easy and reasonably rapid. The goal of this project was to study rural hospitals' access to a DHSL on the Internet, by comparing differing access speeds with differing costs and their acceptability for retrieving text, image, and video information in a DHSL. METHODS: DHSL system response time was measured at three different times during the day over three different types of network connections (T1, Frame Relay, Modem). Text, image, and video information was retrieved. Costs were determined for installation and operation of the different types of network connections. RESULTS: System response times were consistent at the three different testing times for each media type retrieved by each of the three network connection types. System response times for text retrieval met literature standards for all connections. Image retrieval met literature standards for T1 and Frame relay connections. No connection met literature standards for video retrieval. CONCLUSIONS: High speed access to DHSLs is preferable; Frame relay connections provide substantively similar service as T1 connections at less cost. However, access via modem to a DHSL can provide access to the majority of information--text--in a DHSL with an acceptable system response time.

Barriers to rural physician use of a digital health sciences library.

BACKGROUND: Rural physicians need access to quality medical information, but accessing information is difficult in rural settings. Digital health sciences libraries (DHSLs) offer the potential to make information more accessible to rural physicians. A telemedicine network was deployed to six rural hospitals in Iowa. Computers were installed allowing access to a DHSL and training sessions were held. The purpose of this study was to examine the barriers to use of a DHSL by rural physicians. METHODS: Approximately one year after deployment of the telemedicine network, physicians were surveyed using a modified critical incident technique. RESULTS: Seventy percent of the eligible physicians responded and 33% had used the DHSL. Primary barriers included insufficient training, being too time consuming to use, and distance of computers from physicians' practice sites. Non-DHSL users cited the difficulty of using the DHSL as their greatest barrier, while DHSL users cited the quality of the information resources. CONCLUSIONS: This study identifies a number of barriers that exist to rural physicians use of a DHSL. Potential solutions to these barriers are discussed. DHSLs will finally reach their potential when they can be delivered by easy to use handheld computers seamlessly integrated into the rural physician's workflow.

Outreach education to improve quality of rural ICU care. Results of a randomized trial.

This study tests whether an outreach educational program tailored to institutional specific patient care practices would improve the quality of care delivered to mechanically ventilated intensive care unit (ICU) patients in rural hospitals. The study was conducted as a randomized control trial using 20 rural Iowa hospitals as the unit of analysis. Twelve randomly selected hospitals received an outreach educational program. After review of the medical records of eligible patients, a multidisciplinary team of intensive care unit specialists from an academic medical center delivered an educational program with content specific to the findings and capacity of the hospital. The outcome measures included patient care processes, patient morbidity and mortality outcomes, and resource use. Results indicated that the outreach program significantly improved many patient care processes (lab work, nursing, dietary management, ventilator management, ventilator weaning). The program marginally reduced hospital ventilator days. Both total length of stay and ICU length of stay fell markedly in the intervention group (by an average of 3.2 and 2.1 d, respectively), while the control group fell only 0.6 and 0.3 d, respectively. However, these effects did not reach statistical significance. Unfortunately, the program had no detectable effects on the clinical outcomes of mortality or nosocomial events. We conclude that an outreach program of this type can effectively improve processes of care in rural ICUs. However, improving processes of care may not always translate into improvement of specific outcomes.

Nurses' perceptions of why medication administration errors occur.

Nurses play a key role in medication administration in hospital settings. Five categories of reasons for medication errors were identified in a survey of 1,384 nurses. These categories include physician, systems, pharmacy, individual, and knowledge-related factors. In this article, issues surrounding the occurrence and prevention of medication errors are discussed.

Trends and implications of visiting medical consultant outpatient clinics in rural hospital communities.

The emergence of visiting consultant clinics (VCC) represents an unstudied but potentially important mechanism for importing specialty physician services into rural areas. An analysis of five years of one state's VCC experience reveals a substantial increase in both availability and geographic accessibility. This study documents the market's response to the oversupply and hypercompetition among urban-based physician specialists. Patterns of VCC growth have varied markedly for different specialties.

Health care providers' perceptions of telemedicine services.

OBJECTIVE: To assess the level of consensus among the administrative and health care leaders at rural Iowa hospitals regarding service gaps and priorities for developing telemedicine services. METHODS: In the summer of 1994, a survey was conducted of all rural hospital chief executive officers, chiefs of medical staffs, and directors of nursing in Iowa concerning their perceptions of telemedicine services. RESULTS: With the exception of teleradiology, few clinical specialties received high ratings as areas of need or priorities for the development of telemedicine. There was a general lack of agreement among respondents from the same hospital on such priorities. In contrast, respondents expressed higher priorities for the development of telemedicine-based educational services. CONCLUSIONS: The interest in teleradiology is consistent with the fact that teleradiology has been more thoroughly tested for medical efficacy than other telemedicine applications. Continuing medical education may represent another potential for widespread successful telemedicine application. Financial issues were reported as the greatest barriers to the development of telemedicine systems.

Comparing providers' performance: problems in making the "report card" analogy fit.

This article examines the applicability of a "report card" strategy as a means of differentiating among providers on the basis of performance. The specific focus is on the potential effect of differences in data collection processes on the meaningfulness of subsequent comparisons among similar types of providers. Variations in reported nosocomial infection rates are analyzed in light of differences in reported surveillance practices; data for similar nursing units are analyzed as well. Thirty-one rural, rural referral, and urban acute care hospitals in the midwest participated in the study. The reported nosocomial infection rates for different types of nursing units and different hospital groups varied substantially. Likewise, there were marked variations in the nosocomial infection surveillance practices at the hospitals, which were found to explain some of the variation in the reported nosocomial infection rates for specific types of nursing units and nosocomial infections. The study conclude that differences in data collection processes may result in incorrect conclusions about differences in the quality of care provided by various providers.

Considerations in establishing visiting consultant clinics in rural hospital communities.

Establishing specialty clinics staffed by visiting medical consultants is one way that rural hospitals can increase local access to specialty care. This example of private sector-driven regionalization of health care services typically involves an agreement among urban specialists, rural hospitals, and local primary care physicians. The urban-based physicians provide limited on-site specialty services in the rural community for patients who are referred by local physicians or self-refer to the specialty clinics. The trend toward formalization of regional relationships across large geographic areas prompts both opportunity and need for careful consideration of visiting specialty clinic arrangements in rural hospital communities. This article delineates advantages and disadvantages associated with the development of Visiting Consulting Clinics (VCC) along with some ¿ground rules¿ to consider when establishing this type of service.

Perceived barriers in reporting medication administration errors.

BACKGROUND: Assuring that medication administration error (MAE) reports are reliable and valid is of great significance for the patient, the hospital, and the nurse. In most hospitals, MAE reporting relies on the nurse who discovers an error to initiate an error report, whether the error was committed by that nurse or someone else. Because of the potential for negative consequences, there may be significant disincentives for the nurse to report the error. This, the first of two articles, describes the results of a large-scale survey designed to assess nurses' perceptions of the reasons why MAE may not be reported. The companion article compares nurses' estimates of the extent to which MAEs are reported with the actual reported medication error rates. METHODS: Nurses in 24 acute-care hospitals were surveyed to determine perceptions of reasons why medication errors may not be reported. RESULTS: The factor analysis reveals four factors explaining why staff nurses may not report medication errors: fear, disagreement over whether an error occurred, administrative responses to medication errors, and effort required to report MAEs. CONCLUSIONS: There are potential changes in both systems and management responses to MAEs that could improve current practice. These changes need to take into account the influences of organizational, professional, and work group culture.

Developing a cooperative provider-based statewide peer review service: early experience.

The purpose of this study was to demonstrate the feasibility of a model of overcoming local barriers to physician peer review through development of a statewide provider-based physician peer review service. For this purpose, the cooperative demonstration project of the Institute for Quality Healthcare, The University of Iowa and The Robert Wood Johnson Foundation, was used. A consortium of 43 Iowa hospitals developed a physician peer review service utilizing a pool of physician reviewers from member hospitals. Thirty-six peer reviews were conducted in 23 different hospitals by 37 different reviewers throughout the state of Iowa in the first 2 years of operation. Reviews of surgical specialists, psychiatrists, and psychiatric services were requested most frequently. The satisfaction of hospitals with the physician peer review service has thus far been gratifying. The long-term financial viability of the physician peer review service has yet to be demonstrated. This cooperative organizational model of a provider-based physician peer review service may be reproducible and valuable to health care providers in other parts of the United States.

Adjusting measures of physician availability to reflect importation of physician services into rural areas.

Recent changes in the organization and delivery of physician services in rural areas suggest the need to update how physician availability is viewed and measured. The objective of this study was to empirically examine the effect of rural hospitals contracting with outside physicians for part or all of their emergency room coverage, and the use of urban specialists to staff outpatient clinics, on measures used to assess physician availability. Based on data from one rural state, the findings demonstrate the importance of adjusting for the importation of physician services into rural areas.