PBS program looks at how health professionals are eliminating hospital-acquired infection and medication errors in “First Do No Harm”
People do not enter a hospital thinking the experience may make them sicker or cost them their lives. But that is exactly what is happening everyday around the country. In “First Do No Harm,” the second program in the four-part PBS series, Remaking American Medicine™…Health Care for the 21st Century, viewers will see how health care providers are determined to overcome two major health care challenges – hospital-acquired infections and the devastating impact of medication errors, both of which exact a terrible toll on patients. “First Do No Harm” airs on PBS at 10 p.m. on Thursday, October 12 (check local listings).
Featured in the one-hour program are physicians and hospitals working together in Pittsburgh, Penn. to conquer infection and the commitment Hackensack University Medical Center in New Jersey has made to introducing technology as a way of reducing medication errors. In both communities, health care providers are working to fundamentally transform the way they deliver safe care.
In Pittsburgh, a unique regional effort is underway to eliminate Methicillin-Resistant Staphylococcus Aureus, or MRSA, a deadly hospital-acquired infection that is reaching epidemic proportions across the country. According to the Centers for Disease Control and Prevention (CDC) about 100,000 people die each year from hospital-acquired infections. As many as 40 percent of these deaths are caused by MRSA.
A decade ago, Pittsburgh set out to become home to the safest health care in the nation through a special initiative called the Pittsburgh Regional Healthcare Initiative (PRHI).
Former Secretary of the Treasury and Alcoa Chairman Paul O’Neill, recognized as a major proponent of health care improvement, led PRHI from its inception. O’Neill introduced a radical concept in health care – to get better care, hospitals would have to let down their guard and learn from one another’s successes and failures.
But reaching the type of transparency envisioned by O’Neill and others is a major challenge. According to Dr. John Jernigan, a CDC expert on hospital-acquired infections, “The reason you might not want to work with the hospital across town is, in some sense, it’s your business competitor. And you’re sharing bad things that have happened in your hospital as well as the successes. You're worried that fellow is going to use those to some competitive advantage. These are real world things.”
In many cases patients bring infections with them, especially those who move or are transferred among various health care institutions seeking care. Physicians, including Dr. Richard Shannon, chief of medicine at Allegheny General Hospital, believed that little could be done about hospital-acquired infections. But that all changed when he met O’Neill and then was inspired and motivated by the commitment of the Pittsburgh VA, the CDC, the Allegheny County Health, and others aligned with PRHI to take on MRSA.
One of those leading the war on MRSA is Dr. Robert Muder, chief of infection control at the VA Pittsburgh Healthcare System. “If hospitals had a comprehensive program to reduce or eliminate MRSA transmission, there would really be no way for patients to acquire it. What that would take is for all the hospitals, nursing homes and health care facilities in a region to get very, very aggressive about controlling the spread of MRSA from patient to patient,” said Dr. Muder.
Encouraged by the efforts of PRHI participants, Dr. Shannon’s objective was to eliminate infections, caused by large catheters placed into veins (commonly called central lines), in two of his hospitals’ Intensive Care Units. His team set a goal of zero infections. But first, he had to prove to hospital administrators that preventing infections would save the hospital money. According to Dr. Shannon the hospital was losing up to $17,000 per patient due to infection. More importantly, Dr. Shannon and his team slashed the number of central line infections from 49 to six and the number of patient deaths from 19 to one in the first year.
Being exposed to hospital infections is not the only concern patients and their families must consider. As many as 98,000 Americans die in hospitals each year according to the Institute of Medicine (IOM). The IOM reports that 7,000 of these deaths are caused by medication error.
Since 1992, the Food and Drug Administration has received about 20,000 reports of medication errors. These are voluntary reports, so the number of medication errors that actually occur is thought to be much higher.
A few years ago, 89-year-old Anna Terrano was brought to the emergency room of Hackensack University Medical Center (HUMC). Like many patients, she suffers from a variety of illnesses. Despite an attentive staff, Mrs. Terrano’s condition only worsened during this hospitalization. Anna’s primary care physician, Dr. Lauren Koniaris, was stunned when she discovered that a transcription error prevented Anna from receiving medication she depended on to control her pain. Mrs. Terrano was clearly suffering. While Mrs. Terrano did not die, the mistake caused her needless suffering.
Experiences like Mrs. Terrano’s are multiplied by the thousands in U.S. hospitals. Dr. Koniaris noted, “When the study came out about medication error and unnecessary deaths in the United States, I said, ‘Oh no, that can’t be the case.’ But, you know, the more you think about it, the more you realize they’re probably right.”
When Anna Terrano was admitted, the computerized ordering system was not available on her floor. Had Dr. Koniaris been able to order medications through the computer rather than by hand, Anna would not have suffered for days in pain.
Dr. Gerard Burns, who is the director of informatics at HUMC, said, “Errors occur when the nurse tries to read the doctor’s orders or the pharmacist enters a medication in the computer system wrong or the information isn’t placed in the patient’s chart.”
At HUMC, doctors are slowly turning to information technology (IT) as a way of reducing errors such as the one Mrs. Terrano had to endure.
The hospital has invested $40 million in a sophisticated information technology system that allows doctors to order medications and tests and communicate with other providers. According to BusinessWeek, Hackensack is now considered one of the most “wired” hospitals in the nation.
But even if a hospital agrees to invest in IT, as Hackensack did, it must convince physicians to use it. It’s a struggle that affects the safety of everyone who goes into a hospital, especially patients like Mrs. Terrano.
Dr. Lauren Koniaris was one of the early advocates for the HUMC system, but her situation is unique. She was introduced to IT as an integral part of medicine while she was still in her residency at Brigham and Women’s Hospital in Boston. This is not the case with older physicians who likely did not receive this type of training.
“I sit at the computer, write medication x and it goes directly down to the pharmacy. Nothing has to be transcribed. It gets rid of all those potential errors.” For Dr. Koniaris, the reason for learning the system is simple – computers help prevent errors that can harm her patients, like Mrs. Terrano.
Dr. Koniaris is known among her physician colleagues as a champion of Hackensack’s computer ordering system because she knows that it helps prevent errors that cause harm and death to patients. The challenge is convincing the other 1,400 independent doctors like Dr. Koniaris to use the technology now available at Hackensack.
“I can understand where the doctors that aren’t really embracing these technologies are coming from,” said Dr. Burns.
Dr. Burns reports that progress has been slow but steady. He and his team work with doctors one by one, and to date about 200 doctors have been trained to use the system.
“First Do No Harm” was produced, written and directed by Marc Shaffer and Frank Christopher.
Crosskeys Media®, producers of Remaking American Medicine™…Health Care for the 21st Century, is a group of award-winning filmmakers. Frank Christopher is Executive Producer and Matthew Eisen Co-Executive Producer. Peabody and Emmy Award-winning journalist John Hockenberry serves as the series host.
Funding for Remaking American Medicine was made available by lead sponsor the Amgen Foundation with major underwriting from The Robert Wood Johnson Foundation®. The Nathan Cummings Foundation provided additional funding.
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