Memorial Healthcare System (Miramar, FL) earned recognition as a finalist for ECRI's 14th Health Devices Achievement Award for its project to reduce medication errors by automating the capture and documentation of patient weights. The changes have led to more accurate documentation of patient weights, resulting in more efficient patient care throughout the health system.
The Health Devices Achievement Award recognizes outstanding initiatives undertaken by member healthcare institutions to improve patient safety, reduce costs, or otherwise facilitate better strategic management of health technology. For details about the winning submission and other finalists, see
The Health Devices Achievement Award: Recognizing Exceptional Health Technology Management.
ECRI congratulates Lisa Lanigan and the rest of the Memorial Healthcare System team.
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Memorial Regional Hospital. (Image courtesy of Memorial Healthcare System.) |
The Challenge
To eliminate or reduce weight-based medication errors by improving the accuracy of documenting patient weights in the electronic medical record (EMR) compared to manual entry.
The Context
A patient's weight provides vital information for calculating proper medication dosages. Thus, it is imperative that patient weight be recorded accurately. Memorial Healthcare System (MHS) in South Florida set a goal to decrease or eliminate medication dosing errors. The health system had found that many of these errors were caused by incorrect patient weight values entered by clinicians into the EMR. An investigation revealed the following areas that required improvement:
1. Transposition: Taking a patient's weight in pounds, but inadvertently entering the value as kilograms in the patient record (e.g., entry of 180 kg for a patient weighing 180 lb). This resulted in a more than two-fold dosing error.
2. Omitting a decimal point: This resulted in a 10-fold discrepancy in actual versus recorded weight.
3. Adding an extra digit to the weight: This resulted in a 100 kg discrepancy.
4. Entering the patient's self-reported weight instead of recording and entering their actual weight
The Process
MHS sought a technological solution to tackle the problem, and worked to integrate its scales with its EMR: By allowing data to be captured directly from the scales and sent to the EMR, the integration solution would largely eliminate the human component from the weight-documentation process, thus enhancing patient safety.
However, the organization's initial exploration of the capabilities of its scales and of the solution available from its integration vendor made it clear that this wouldn't be a simple "plug-and-play" exercise: Although the available technology provided a limited ability to send data from the organization's scales to the EMR, the resultant workflow was too cumbersome for users and still required additional steps within the EMR to get the weight to the correct patient's record.
MHS worked with the integration vendor to tailor the scale integration solution to the organization's needs. Eventually the vendor released new functionality that enabled patient weights to be captured directly from the scales and then sent to the patient's record without the need for any additional steps within the EMR. This provided a more seamless workflow, allowing the project to move forward. To accommodate the upgrade, MHS retrofitted its scales with RS232 ports that were compatible with the solution hardware and replaced any scales that could not be retrofitted. In addition, the following improvements were made:
1. As an added safety measure, all scales were set to weigh in kilograms only, to reduce the potential for measurement-unit mix-ups.
2. To promote ease of use, the organization installed on each scale (1) a bar-code scanner to promote positive patient identification and (2) the integration solution's point-of-care (POC) hardware component, which captures and displays the weight measurement and provides a user interface from which the clinician verifies the measurement and sends it to the EMR.
An unexpected hurdle was encountered as the POC hardware components were installed on the organization's standing scales: The additional hardware made the scales top-heavy. MHS worked with a third-party vendor to fit the scales with a counterbalance weight to prevent them from tipping over.
Under the new workflow, users do the following:
1. Log on to the POC hardware component using their network credentials
2. Scan the patient's wristband (allowing identification at the point of care)
3. Confirm the patient's identity with two patient identifiers
4. Zero the scale, then weigh the patient. The data is automatically transferred to the POC hardware component, eliminating the need for any manual entry.
5. Confirm that the data displayed on the scale and on the POC hardware component match, then send the data to the EMR. No further action is required once the weight gets to the EMR, because the user has already validated the data at the point of care.
A pilot of the integration in a pediatric ER received very positive feedback from clinicians and leadership, and the first two facilities, Joe DiMaggio Children's Hospital and Memorial Regional Hospital, went live house-wide in January 2017. Since then, the other facilities have followed. The technology is currently used in the hospitals' emergency rooms and medical/surgical units.
The Results
Since rolling out the program, MHS has had fewer reported weight-based medication dosing errors. Data from the first two facilities to implement the integration shows an 83% reduction in inaccurate weight documentation. This 17% margin corresponds to only a single incident of inaccurate weight documentation since the program launch. Notably, the error did not compromise patient care, and occurred with use of a bed scale in an adult ICU; the bed scales in Memorial's ICUs, along with the infant warmer scales in its neonatal ICUs, are not currently integrated and thus still require manual entry of patient weight values into the EMR. As an additional safety layer, a pharmacist verifies all weight entries, whether done manually or electronically.
An ancillary benefit of the program is that the patient's weight is now displayed in the EMR in very near real time, eliminating the wait time until the clinician can get to a computer to enter the weight manually.
Overall, the changes have resulted in safer and more efficient patient care throughout the health system.
Key Takeaways
This project shows that it doesn't take a large-scale initiative to produce significant benefits. A more focused change, targeted at the right problem and well executed, can have a significant impact.
The effort also illustrates the importance of not just getting a process improvement to work, but getting it to work well. If a new process doesn't function smoothly, end users may not adopt it—and expected safety benefits may never materialize. By devoting the necessary time and effort to improving the initial integration—and, in turn, the users' experience—MHS achieved buy-in from staff and scored a win for patient safety.