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Low-Tech Safety

Jay Moore, for HealthLeaders Media, February 4, 2009
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Hospitals have increasingly turned to advanced technology to help keep patients safe. But some providers are discovering that there are considerable virtues in simplicity.

As the challenge of keeping patients safe has grown more complex, so have many of the solutions. From radio frequency identification to computerized medication administration to bar coding, technologically advanced initiatives designed to reduce errors and protect patients have become more prevalent as provider organizations struggle with drug-resistant infections, overworked caregivers, overcrowded facilities, and simple human imperfection.

But at Kaiser South San Francisco Medical Center, one of the most decidedly low-tech patient safety solutions has proven to be the most effective. The 120-licensed-bed California hospital has seen a significant reduction in medication errors from its medication vest program, in which nurses wear specific apparel when dispensing medications to indicate they are not to be bothered, thus reducing distractions. Despite a higher patient census, the hospital cut medication errors by 50% in January 2008 compared to January 2007, says Becky Richards, RN, adult clinical services director.

Such solutions don't always represent the newest in patient safety theory—medication vests, for instance, have been around to a limited extent for years. But a combination of concrete results and recent academic research have helped fuel a growing school of thought in patient safety circles that despite the technological innovations of recent years, low-tech solutions can yield meaningful results when it comes to reducing errors.

Immediate results
Kaiser South San Francisco's low-tech initiative almost never happened. After approving a pilot of the med vest program in 2006, hospital leaders quickly encountered severe pushback. "The first ones were bright orange. They were horrible," Richards says. "Physicians were scoffing, nurses were upset—we were going to abandon the program because it was so unpopular."

But the hospital almost immediately saw results it couldn't ignore. Kaiser South San Francisco initially piloted the program in its orthopedic unit, which had the facility's highest medication error rate, and soon expanded it to a second unit. The two units saw a 47% error decrease in five months, Richards says—and staff members began to understand the genuine importance of focusing on a single task when dispensing medication. "We think it's marvelous when people can do two, three, four things at a time," she says. "But if there is ever a time when there should be no multitasking, it's during medication administration."

Armed with tangible results, the hospital upgraded the vests—they are now a more muted yellow, made of a more comfortable material, and are available as a full vest or a sash—worked to cultivate a physician champion, and relaunched the initiative hospitalwide in April 2007, with each nurse getting his or her own vest. After 30 days, the hospital reduced medication errors by 20%, Richards says.

The program has expanded to multiple other Kaiser hospitals, including 20 in Northern California and one each in Southern California, Oregon, and Hawaii, Richards says. And at Kaiser South San Francisco, the program's success has also given nurse satisfaction a boost, she says. "This has helped us let nurses know that we respect their time, we respect the importance of giving patients proper medication in a timely manner. Now nurses are eager to tell us other things about improving other systems."

Looking at labels
While some organizations such as Kaiser South San Francisco may be realizing positive error-reduction results from certain initiatives at a local level, formal research into the benefits of low-tech solutions has traditionally been fairly limited. One recent report from a group at the department of anesthesiology at Penn State Hershey (PA) Medical Center, however, attempts to reach some conclusions about the benefits of a simple idea: universalizing the appearance of medication labels.

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