By Tim Bonfield
The Cincinnati Enquirer

At Bethesda North Hospital, nurses are training to use a $3.8 million system that runs IV medications through a machine that looks like a bank of oversized calculators.

Rhonda Wilson, RN, a nurse manager in the Telemetry unit at Good Samaritan Hospital, checks out the Medley Medication Safety System, an intravenous delivery system for medications and fluids. (Gary Landers photo)

At Cincinnati Children's Hospital Medical Center, a $640,000 medication mixing robot will be installed this summer to automatically prepare as many as 600 injections a day.

And this fall at University and Christ hospitals, a three-year program begins to encourage doctors to order medications via computer rather than handwritten slips of paper.

These and other hospitals in Greater Cincinnati are pumping millions of dollars this year into ways to reduce the number of deaths, injuries and treatment problems that can result from medication errors.

"In every hospital, medication errors occur every day," says Sandi King, manager of clinical safety for the TriHealth hospital group.

"Human errors occur because we are human. We get tired. We have too many irons in the fire."

Although no local statistics are available, an estimated 44,000 to 98,000 people a year die from medical errors of all kinds in hospitals nationwide. Of those, medication errors account for about 7,000 deaths a year, according to the Institute of Medicine.

Medication errors also can lead to disabilities, lawsuits and uncounted millions spent on longer hospital stays and emergency treatments.

Since the late 1990s, regulatory agencies, consumers and other interest groups have demanded that hospitals do more to reduce medication errors. In Cincinnati, that pressure has resulted in a wave of spending on new technology.

With so many patients using so many medications, it is easy to imagine that mistakes will be made.

The doctor might misspell the medication. The pharmacist might misread the doctor's instructions. The nurse might punch one too many zeros into the pump that sets the drip rate.

Patients at TriHealth hospitals use more than 550,000 IV bags of medication a year. To replace its lower-tech infusion pumps, the hospital group has turned to San Diego-based Alaris Medical Systems.

The company is one of a handful nationwide that make "smart" infusion pumps that can alert staff if a prescribed dose falls outside pre-programmed high and low dose ranges. Software tracking systems also can send "near miss" reports to hospital administrators.

So TriHealth plans to replace about 625 infusion pumps with the new Alaris system. Not only does the system sound alarms, it can keep track of near-misses for quality improvement reports.

A new approach

Before automation, hospitals relied on a "Swiss cheese" approach to avoid medication errors, says Jack Horn, director of pharmacy for Cincinnati Children's.

While no single human is perfect, errors can be reduced by having multiple people checking that the right medication dose is going to the right patient. Doctors, pharmacists, nurses, technicians, even patients and family members have roles to play - much like layers of Swiss cheese with holes in different places.

"But eventually, the holes line up and an error gets through," Horn said.

The IntelliFill robot system to be used at Children's Hospital is made by Florida-based ForHealth Technologies Inc.

The device is about the size of three refrigerators strapped together and can fill 300 syringes an hour - each with a custom dose and a bar code label routing it to a particular patient.

Such a robot is especially useful in a pediatric hospital because doses have to be adjusted by a patient's weight.

A paperless future?

The Health Alliance of Greater Cincinnati is talking with two vendors about replacing its IV infusion pumps and is considering buying a medication mixing robot, said Dr. Marianne Ivey, director of pharmacy services.

But the most far-reaching project for the Health Alliance will be installing a computer order-entry system to replace handwritten prescription orders from doctors.

The project is expected to take three years to fully install. Small pilot projects involving parts of University and Christ hospitals will begin this fall, Ivey said.

The move would make the Health Alliance the first adult hospital in town to follow Children's Hospital, which launched a similar program in 2002.

Mercy Health Partners plans to spend $25 million in the next five years on error-reducing technology, including about $10 million to install a computer order entry system by the end of 2005, says Jana Deen, regional vice president of patient safety support.

Mercy Health Partners does not plan to buy robotic systems, but smaller projects, including computerized pill dispensing systems, already have been started at all five area Mercy hospitals. Upgrades to infusion pumps also are planned.

"We're already seeing some improvements. We expect to see more," Deen said.

Small hospital challenges

Error-reducing technology ranges widely in Greater Cincinnati. Smaller hospitals with fewer patients have less ability to spread the costs of technology buys.

"We're too small for robots and those kinds of things. But there are a lot of other things you can do to reduce medication errors," says Sylvia Burkey, chief operating officer for McCullough-Hyde Memorial Hospital in Oxford.

For example, the hospital has spent tens of thousands on upgraded infusion pumps and an automated pill-dispensing system.

But Burkey said it could be years before small hospitals can afford to invest in computerized ordering systems.

"Those kinds of things cost a lot of money. And Medicare doesn't increase our reimbursement rates for doing these things," Burkey said.

So instead of relying so much on hardware, smaller hospitals are looking at ways to improve training and organization for staff.

"It's as much about organizational review as about buying a particular piece of technology," she said.

Machines make mistakes too

Anyone familiar with software bugs and power outages knows that machines make mistakes, too.

At Children's Hospital, pharmacy staff already run daily validation tests on medication systems. They expect to make frequent checks on the new syringe-mixing robot as well.

So even though the new machines will help reduce human error, Horn says, hospitals will always need people to check the machines.

The impact of medication errors

• 44,000 to 98,000 people a year die from medical errors in hospitals nationwide.

• 7,000 of those deaths are blamed on medication errors.

• $37.6 billion is spent annually because of medical errors.

• Adverse reactions to drugs injure more than 770,000 people each year in hospitals.

• Patients who have adverse drug reactions were hospitalized an average of 8 to 12 days longer than similar patients.

• Between 28 percent and 95 percent of adverse reactions can be prevented through computerized monitoring systems.

• Computerized medication order entry may prevent an estimated 84 percent of dose, frequency, and route errors.

--Sources: The Institute of Medicine and the Agency for Healthcare Research and Quality, an arm of the U.S. Department of Health and Human Services

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E-mail tbonfield@enquirer.com