Cath Lab Digest - September 2007 - (Page 54)

54 CLINICAL AND INDUSTRY NEWS SEPTEMBER 2007 Study Indicates Abbreviations Pose Threat to Patient Safety A lthough abbreviations in health care may be efficient, their use comes at the expense of patient safety, according to a new study published in the September 2007 issue of The Joint Commission Journal on Quality and Patient Safety. The findings of this study provide further support for The Joint Commission’s “Do Not Use” list of abbreviations that is part of its National Patient Safety Goals. The study also suggests the need to consider additions to the “Do Not Use” list. Although abbreviations are known causes of medication errors, the study, entitled “The Impact of Abbreviations on Patient Safety,” is the first to examine the exact characterization and impact of these errors. The study collected and analyzed data through a retrospective review of errors resulting from abbreviations as reported to the United States Pharmacopeia’s MEDMARX®, a national database for medication errors, from 2004 through 2006. The study found that nearly 5 percent of all errors reported to MEDMARX ® during this time period were attributable to abbreviations. This analysis of nearly 30,000 medication error reports involving abbreviations suggests that health care organizations should consider additions to the “Do Not Use” list. Candidates for an expanded list include drug name abbreviations (for example, PCN, DCN, TCN), stem abbreviations (amps, nitro, succs), µg (mcg), cc (mL), and dose scheduling (BID, TID, QID). The authors of the study, led by Luigi Brunetti, PharmD, a clinical assistant professor at the Ernest Mario School of Pharmacy at Rutgers University, Rutgers, NJ, note that communication is the leading cause of sentinel events and that abbreviation use hinders communication. Sentinel events are unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof, that are tracked by The Joint Commission. The study also characterizes error-prone abbreviations as preventable problems that are a logical area for improvement. The notable findings in the study include: • The most common abbreviation resulting in a medication error was the use of “qd” in place of “once daily,” accounting for 43.1 percent of all errors. • The other most common abbreviations resulting in medication errors were “U” for units, “cc” for mL, “MSO4” or “MS” for morphine sulfate, and decimal errors. • Eighty-one percent of the errors occurred during prescribing, while errors during transcribing and dispensing were much less frequent, representing only 14 percent and 2.9 percent of errors, respectively. • Abbreviation errors originated more often from medical staff in comparison to nursing, pharmacy, other health care providers, and non–health care providers. • The three most common types of abbreviation-related errors were prescribing, improper dose/quantity, and incorrectly prepared medication. The study also found that in nearly 40 percent of the errors in which abbreviations were identified as the cause of error, the exact abbreviation was unidentified. The authors urge individuals and organizations reporting medication errors to include the key points that adequately describe the error, including the cause of the error, a brief description of the cause (in the case of abbreviations, which abbreviation), the contributing factors, the outcome, staff involved, and the point in the medication process when the error occurred in order to learn from the errors and improve patient safety. ■ Progressive Trend Toward Interventional Procedures Challenges Cardiac Surgery Devices Market T he national focus on cardiovascular health is all-pervasive. Almost every supermarket and specialty food store has products promoting their benefits for the heart. Everything from cereals high in fiber to orange juice fortified with vitamins claim to reduce the risk of heart disease. Once considered bad due to their high fat content, meats, eggs, and cheese are currently marketed as part of a heart-healthy diet in the context of a high-protein, low-carbohydrate diet. Additionally, products such as aspirin are marketed to be beneficial to patients at risk for heart disease. New analysis from Frost & Sullivan (http://www.medicaldevices.frost.com) entitled U.S. Cardiac Surgery Devices Market, finds that the number of coronary artery bypass (CABG) procedures performed in the United States was 330,669 in 2006 and estimates a steady decline, reaching to 223,036 procedures in 2013. Despite warnings and growing awareness, obesity rates among adults and children are soaring. Statistics indicate the childhood obesity rate is around 16 percent, nearly double the rate it was in 1980. Nearly one in four deaths in the United States is due to cardiovascular disease, with nearly 1.2 million cases of heart attacks reported each year. There are six million people living with angina, who on average will require three to four repeat procedures throughout the rest of their lives. Current trends would indicate that future patients are likely to develop vascular diseases at a much younger age than previously witnessed. Though alarming from a national health perspective, all of these statistics represent significant increases in the number of interventional vascular procedures performed and a strong future for the cardiovascular segment. Thus, the cardiovascular sector of the medical device industry is the largest and most robust of any field in medical devices. Advances in percutaneous coronary intervention (PCI), such as rapid exchange catheters, intravascular imaging, and the introduction of drug-eluting stents, affects the usage rates of coronary artery bypass grafting (CABG). Furthermore, CABG is traditionally one of the most commonly performed surgical procedures in the United States. Although there are some concerns about the safety of drug-eluting stents, healthcare facilities appear to favor minimally invasive alternatives over bypass grafting. With the entry of more sophisticated second- and third-generation drugeluting stents capable of addressing existing issues related to thrombosis and restenosis, the utilization of CABG procedures is likely to further decline The two most critical concerns associated with any kind of procedure performed on the heart are accuracy and time. Outside of CABG procedures, there are a number of high-growth sectors in the U.S. cardiac surgery market, such as surgical cardiac ablation. These newer advanced procedures require the highest level of precision and accuracy in order to witness even moderate levels of clinical efficiency. Recent advances in robotic-guided technology have the potential to drastically improve the success rates of cardiac ablation procedures and several robotic assist manufacturers are already eyeing the cardiac surgery market as a key area of focus. With robotics, it is possible to directly translate the information from a 3-D mapping of the heart to a robot that could determine the exact location of the arrhythmia and the size of lesions required to treat it. This considerably improves both the time and accuracy of cardiac ablation procedures. U.S. Cardiac Surgery Devices Market is part of the Medical Devices Subscription, which also includes research in the following markets: U.S. Carotid and Intracranial Devices, U.S. Cardiac Rhythm Management Market, and U.S. Congestive Heart Failure Devices market. ■ http://www.medicaldevices.frost.com

Table of Contents Feed for the Digital Edition of Cath Lab Digest - September 2007

St. Dominic Hospital The Genous Bio-engineered R Stent Percutaneous Treatment of Peripheral Arterial Chronic Total Occlusions: Device Options and Clinical Outcomes Contents Clinical Editor’s Corner Percutaneous Revascularization of Peripheral Chronic Total Occlusion — Which Patients, Why, and How? Myocardial Infarction and Syncope: A Manifestation of the “Raynaud-Prinzmetal Syndrome”? Essential Technical Components of the Transradial Approach If You Build It, Will They Come? Evidence-Based Medicine with Drug-Eluting Stents Back to School: The Value of Education in Cardiovascular Services The ACVP Standards and Competencies: Are You Using Them Effectively? What Do You Think? My Experience with Fibromuscular Dysplasia and Stroke A Brief Review of Fibromuscular Dysplasia Letter to the Editor A Look at On-the-Job Training: Perceptions, Reality and Our Profession Doing the Wave: Inventory Management with RFID The Ten-Minute Interview with… Paul Pinsker, RCIS CLD’s Annual Salary Survey Harrisburg Area Community College Volunteer Survey CEU Education Center SICP* Section Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab Clinical & Industry News

Cath Lab Digest - September 2007

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