I’ve Been Thinking: Clear Eyes. Full Hearts. Can’t Lose. Part II

I’ve been thinking about game plans for improving the accuracy of patient identification with bar coding at the point of care (BPOC).

I’ve borrowed my title for this two-part article from NBC’s Friday Night Lights. It’s the mantra Coach Taylor delivers right before his Dillon Lions take the field: “Clear eyes. Full hearts. Can’t lose.” After a full week of practice and countless X’s and O’s on the chalkboard, the coach’s charge is wind in the team’s sail.

Last month I suggested that winning BPOC initiatives result from having clear eyes (vision). This month I want to talk about the value that full hearts (passion) bring to the mix. If vision is your sail, passion is its wind.

Passion comes from conviction.

My neighbors (an orthopedic surgeon and a general surgeon) have traditionally been glued to Husky football on Saturdays. The other day, however, they told me, “No more.” It’s called parental conviction: “We don’t want Jon (7) to develop interest in a game we are not going to let him play. It’s too dangerous.”

There’s reason for concern. My neighbor has fixed a lot of football knees in greater Seattle. Knees aren’t his problem. On Friday Night Lights, Dillon’s star quarterback became a paraplegic, something that happens in real life too. Ten days ago, a Texas high-school quarterback completed a touchdown pass, collapsed on the sidelines, and died later that night. Between 1997 and 2007, at least 50 high school or younger football players were killed or sustained serious head injuries on the gridiron, according to research by the New York Times. Two college players died from head injuries in the last 10 years.

I don’t want to trivialize lives lost from hits on the gridiron, but what about lives lost from medication errors in hospitals? Six hours ago, KOMO news reported an infant death at Seattle Children’s because a nurse administered 10 times the calcium-chloride dose intended. The Institute of Medicine reported that in 1993 alone, an estimated 7,000 hospital deaths were attributable to medication errors.

But there’s good news too: Back in May, the New England Journal of Medicine reported that by utilizing BPOC, Brigham and Women’s Hospital realized a 41 percent drop in non-timing-related medication errors, which translated into a 51 percent relative reduction in adverse drug events.

While many of us are thrilled with the momentum this study lends to the bedside bar-coding cause, some of us are not surprised with the results. Brigham’s findings reinforce what we’ve heard from other hospitals experiencing similar results with bar coding over the past decade. The Veterans Healthcare Administration, for example, reported as much as a 70 percent reduction in medication errors. The University of Wisconsin Hospital reported an overall 87-percent drop in medication-administration error rates.

Passion comes from facing the need for a safer point of care and understanding the role BPOC can play in achieving a safer point of care.

Passion communicates. Full hearts overflow when there are stories to tell.

It is not uncommon for nurses to be antagonistic, if not agnostic toward bar coding when it first arrives on their units. What nurse needs another thing to do? Consistently, however, nurses have epiphanies the first time scanning prevents them from administering medications that could have harmed their patients. I’ve witnessed nurses not only becoming believers but also evangelists for scanning.

Last night I visited a friend in the ICU of one of the nation’s top ten hospitals. The attending nurse previously worked in a lesser-known hospital that had bar coding. I got an earful. She wasn’t happy that scanning was not available to protect her and her patients in this hospital.

BPOC initiatives benefit from nurses sharing their stories of how bar-code scanning, done the right way, catches errors, prevents harm, and improves quality of care. I’m interested in hearing yours.

Wise hospitals intentionally tell the bar-coding story to their patients. Their nurses explain what they are doing with scanning at the point of care and why.

Some hospitals walk their patients through all-about-bar-coding brochures that are included in admitting packets. Some hospitals have Web pages explaining the what’s and why’s of BPOC. Patients of all ages get it. Scanning especially makes sense to vigilant parents. I’m interested in how you inform your patients about bar coding.

Finally, the hospitals that do the very best with bar coding can’t keep from telling their stories to the world. Not because they want to appear safer than the hospital down the street but because they care. They’re wishing for colleagues and patients everywhere to benefit from bar-code safety technology.

This is what The unSUMMIT for Bedside Barcoding is all about. People with clear eyes and full hearts sharing real-life stories, thus helping each prevent tragedies. I hope you’ll bring your story to Louisville April 27-29, where we will gather for the purpose of “Catching Errors at the Point of Care.”

Clear eyes. Full hearts. Can’t lose.

What do you think?

Mark Neuenschwander a.k.a. Noosh

PS. I really am interested in hearing how you tell your BPOC stories to caregivers in rollout, to patients and their families day-in and day-out, and the to the community outside your doors. Hope to hear from you.

mark@hospitalrx.com
http://twitter.com/hospitalrx