Creating a culture of safety in health care with RFID

The prevalence of medical error in the world, and even in the United States is shocking, and increasing over time according to reports. With RFID though, the conditions and multiple steps/checkpoints that are conducive to human error are dramatically mitigated, and many types of errors and risks can be eliminated altogether.

• Reduced Risk
• Improves Patient Care, and
• Reduces Costs

The combination of these factors optimizes the health care environment for patient safety and staff efficiency. Consider these facts from the Agency for Healthcare Research and Quality (AHRQ):

"Even using the lower estimate [44,000, compared to the higher estimate of up to 98,000], this would make medical errors the eighth leading cause of death in this country—higher than motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516). About 7,000 people per year are estimated to die from medication errors alone—about 16 percent more deaths than the number attributable to work-related injuries¹".

It is suspected that these are both modest estimates, since many errors go unreported^{2, 3}. What's more --most of these errors can be prevented¹:

"One of the landmark studies on medical errors indicated 70 percent of adverse events found in a review of 1,133 medical records were preventable; 6 percent were potentially preventable; and 24 percent were not preventable.

"A study … based on a chart review of 15,000 medical records in Colorado and Utah, found that 54 percent of surgical errors were preventable¹".

Medical insurers – both public and private – are increasingly reluctant to pay for these errors. Medicaid leads the efforts to reduce error with their release of a list of common, preventable errors they will no longer pay for⁴, encouraging providers to step up their efforts to improve.

But who is to blame?

The AHRQ states that it is not the individuals who are faulty, but the systems in place that present so many opportunities for errors to occur and inadequate opportunities for them to be recognized and rectified prior to reaching the patient.

The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)has recommended improvements to these faulty systems, to raise the standards in patient safety⁵. Among the 16 2008 National Patient Safety Goals⁵ are the following:

• Improve the accuracy of patient identification
• Improve the effectiveness of communication among caregivers
• Improve the safety of using medications
• Accurately and completely reconcile medications across the continuum of care
• Reduce the risk of patient harm resulting from falls
• Improve recognition and response to changes in a patient's condition

Universal Protocol steps

• Pre-procedure verification
• Marking procedure site
• Performing a time-out

Information Technology improvements can address at least these seven goals that promote a culture of safety in health care. Studies that have been done on the use of health care IT implementation demonstrate improvements in the safety of patients and staff, improved quality of care, and increased productivity of clinicians.

RFID, specifically, addresses these factors and has virtually limitless applications once the infrastructure is in place. Automating many of these steps greatly reduces the opportunity for medical error through the correct identification of patients and staff, real-time transparency across the continuum of care, real-time location and maintenance management of assets and inventory.

Improve the accuracy of patient identification

RFID wrist bands, handheld readers accurately identify patients every time (Patient & Staff Tracking)

Improve the effectiveness of communication among caregivers

RFID makes real-time changes in EHR accessible to all caregivers, facilitating the accurate and effective communication of key details (Patient & Staff Tracking, Lab & Sample Tracking, Medication Tracking)

Improve the safety of using medications

RFID ensures the right dosage of the right medication is given to the right person at the right time. It can prevent dangerous interactions and associate the caregiver who prescribes/administers the drugs with the patient in the EHR. (Patient & Staff Tracking, Medication Tracking, Inventory Management)

Accurately and completely reconcile medications across the continuum of care

EHR via RFID provides real-time, accurate and complete information across the continuum of care. (Patient & Staff Tracking, Medication Tracking, Lab & Sample Tracking)

Reduce the risk of patient harm resulting from falls

RFID Patient tracking can notify appropriate personnel when patients who are at high risk for falls get out of their beds/rooms, allowing them to respond immediately and restore the patient to safe conditions. (Patient Tracking)

Improve recognition and response to changes in a patient's condition

RFID can enable teams to quickly recognize, locate and reach a patient with the appropriate tools and medications to respond to their condition changes. (Patient & Staff Tracking, Inventory Management, Asset Tracking & Maintenance, Medication Tracking)

Universal Protocol steps

• Pre-procedure verification (Patient & Staff Tracking)
• Marking procedure site (EHR via RFID, Patient & Staff Tracking)
• Performing a time-out (Inventory Management, Asset Tracking & Maintenance, Medication Tracking)

RFID can facilitate a culture of safety and quality in health care environments, resulting in:

• Improved Patient Care
• Reduce Costs, and
• Reduce Risks

Plenty of money is available to help health care organizations adopt IT to improve care. AHRQ grants range from $100,000 - $1.2 million, and the Certification Commission for Healthcare Information Technology reports more than $700 million in funding programs for healthcare IT adoption.

1. Medical Errors: The Scope of the Problem. Fact sheet, Publication No. AHRQ 00-P037. 2000. http://www.ahrq.gov/qual/errback.htm. Published Last Modified Date. Accessed Dated Accessed.

2. Kuehn BM. Reporting Errors. JAMA. February 27, 2008 2008;299(8):890-b-.

3. Miles SH. Wall of Silence: The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans. JAMA. November 12, 2003 2003;290(18):2486-2487.

4. Mitka M. Public, Private Insurers Refusing to Pay Hospitals for Costs of Avoidable Errors. JAMA. June 4, 2008 2008;299(21):2495-2496.

5. 2008 National Patient Safety Goals. Joint Commission on the Accreditation of Healthcare Organizations: Reprinted by permission of the Joint Commission; 2008: http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/09_hap_npsgs.htm. Accessed.

6. Macario A, Morris D, Morris S. Initial Clinical Evaluation of a Handheld Device for Detecting Retained Surgical Gauze Sponges Using Radiofrequency Identification Technology. Arch Surg. July 1, 2006 2006;141(7):659-662.

DCC provides scalable RFID solutions that meet three key health care objectives: improving patient care, reducing costs and minimizing risks. Our solutions deliver rapid ROI on your nominal investment by integrating RFID technologies with your existing systems to automate operations and eliminate error.

DCC selects the best RFID hardware, software and tags in functionality and value, for the health care environment. With no vested interest in any particular technology or brand, you can rest assured that we have the right prescription to eliminate the "pains" in health care.