Dual HIT Programs Reduce Medication Errors at Hopkins

At the time that the drug ordering system was installed, Hopkins began using the Patient Safety Net error reporting system, a Web-based reporting tool. When a mistake is made it is to be reported on the PSN. This system allows for follow up, corrective action, and the ability to learn from common mistakes. It also categorizes unsafe conditions and near-miss events.

Jayaram says the HIT programs have helped to create a "culture of safety" in the psychiatry department, along with annual safety training, reporting of all adverse events as they occur, and feedback that focuses not by blaming, but on how to prevent a reoccurrence through education and corrective action.

While medication mistakes involving psychotropic drugs are rarely deadly, Jayaram said psychiatric patients also take other kinds of medication — insulin, blood thinners, and others that can be lethal if given in the wrong doses or in the wrong combination. In a psychiatric department some nonpsychotropic medications are considered high-risk and, as a precaution, two nurses must check them off before they are administered.

Even with computerized backstops, Jayaram said complacency can be a problem and new problems can arise so the system is constantly evolving. "You have to be vigilant for new problems that might come up," she said.