One method that Holzer utilizes to provide safe patient care during a hospitalization is Bar Code Medication Administration (BCMA). BCMA is an electronic method of verification that provides an efficient check of the 5 Rights of Medication Administration, the right patient, the right medication, the right dose, the right time, and the right route. This technology provides a workflow process that limits the chances of human error.
During the process nurses scan both the patient armband and the medication. The system then notifies the nurse if any of the 5 Rights do not match up, allowing the nurse a double check of the medication order and patient.
A medication error is commonly known as “any preventable event that may cause or lead to inappropriate medication use or harm while the medication is in the control of the healthcare professional, patient, or consumer” (Tariq RA, 2023). One study estimates that 10% of hospitalized patients will have an experience with a medication error (Zauderer, 2023). The monetary cost of providing care to patients with medication-related errors exceeds $40 billion a year (Tariq RA, 2023). These types of errors don’t only influence cost of care, they also have an emotional and physical effect on patients, families, and staff members. Utilizing BCMA has shown a reduction of 50% in adverse drug events in the inpatient setting, as well as a reduction of 80% within the emergency department setting (Leapfrog Group, 2020).
Patient safety at all stages of care is a high priority at Holzer. All inpatient units and Emergency Departments utilize BCMA for medication administration. Each unit has a goal of 95% compliance with scanning both patient armbands and medications and are monitored to ensure the high standards are maintained. Monitoring unit compliance allows identification of areas for improvement that can then be addressed quickly and efficiently. Units with consistently higher than goal compliance rates are recognized each quarter for providing safe and high-quality care to their patients.
A BCMA team meets regularly to analyze data and methods of constantly improving scanning rates. The BCMA team consists of multiple departments, which provides different viewpoints and knowledge concerning the scanning process. The team provides support to staff in many ways, such as ensuring they have the equipment needed to scan correctly. Holzer voluntarily reports BCMA data to the Leapfrog Hospital Survey annually. This data is then reported publicly on their website and utilized in their Leapfrog Safety Grade. For more information on BCMA, Holzer data, and Leapfrog, visit:
Leapfrog Hospital Survey
Leapfrog Safety Grade
Over the past several years, Holzer has dramatically improved the quality of sepsis care we provide our communities, with the goal of quick recognition and rapid treatment. This truly takes a team effort, and Holzer’s Sepsis Committee has been working hard to make sure staff and providers have the tools they need to provide excellent sepsis care, every patient, every time. Because of the work of our Sepsis Committee, we are now consistently performing well above the state and national averages for quickly utilizing the sepsis treatment bundle.
To celebrate Sepsis Awareness Month, Holzer’s Sepsis Committee hosted Sepsis Week activities September 11-15, and traveled to our inpatient units and emergency departments to talk with our staff and providers about sepsis. At Holzer, you and your loved ones can count on quick recognition and treatment of sepsis to provide the best possible care, and to decrease long-term complications.
For more information on sepsis, visit www.sepsis.org.
Improving outcomes for patients that have had medical emergencies is one of many quality goals within Holzer Health System.
Medical emergencies, or “code blue,” occur when adult patients experience a loss of respiratory and/or cardiac function or may include any other medical emergency. Staff that are with the patient send an alert and a trained team responds to provide immediate medical attention. The team that arrives is specially trained in Advanced Cardiac Life Support (ACLS). This training allows team members to assess, recognize and manage medical emergencies. ACLS protocols are evidence-based and consistently updated allowing fast and effective interventions. Since certification is required every two years, staff stay up to date with new and improved management techniques. The responders include a physician, respiratory therapist, nurses, and laboratory personnel. Each member plays a vital role in the care of the patient, which requires clear communication and teamwork.
A code blue committee was developed to look specifically at ways Holzer could improve response time, interventions, and patient outcomes. This group gathers data and analyzes all medical emergency events with only one goal in mind, to improve patient care.
Since the group began, many changes have occurred including easier documentation, mock code blue drills, code blue classes and participating in the American Heart Association's Get with the Guidelines – Resuscitation program.
Mock code blue drills occur throughout the system both in the hospital and clinic settings. Debriefing occurs after the drill to discuss with the staff what went right and opportunities for improvement. The code blue classes are held for all staff members that want to increase their knowledge in the code blue response process.
The Get with the Guidelines program allows Holzer to compare itself to other facilities and provides guidance and education through regular educational meetings involving hospital facilities throughout the country. Data has shown that the changes and awareness that the code blue committee put into action have made a positive impact. Improvements have been noted in medications and response times as well as other areas. The code blue committee continues to work with staff to provide training, education, and awareness as they work towards the goal of high-quality patient care.
"A urinary tract infection (UTI) is an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney. UTIs are the most common type of healthcare-associated infection reported to the National Healthcare Safety Network (NHSN). Among UTIs acquired in the hospital, approximately 75% are associated with a urinary catheter, which is a tube inserted into the bladder through the urethra to drain urine. Between 15-25% of hospitalized patients receive urinary catheters during their hospital stay. The most important risk factor for developing a catheter associated UTI (CAUTI) is prolonged use of the urinary catheter. Therefore, catheters should only be used for appropriate indications and should be removed as soon as they are no longer needed.”
Source: According the Centers for Disease Control and Prevention (CDC), see CDC information here
Historically Holzer has very few infections that meet the NHSN definition of CAUTI. We had an average of 3 per year for the 5-year period prior to the start of the COVID Pandemic. During the Pandemic, we saw an increase in our usage of indwelling urinary catheter and an increase in related Urinary tract infections. Seeing this increase a team was pulled together to identify and address issues. In April 2022, due to interventions such as daily review for the need of a catheter, introduction of external urinary collection devices and an enhanced personal cleansing process we successfully decreased not only our UTI infection rate (Zero CAUTI since April 2022) but the use of foley catheters in our patient population.
See more information about Catheter Associated UTIs
