U.S. Office of Personnel Management - Recruiting, Retaining and Honoring a World-Class Workforce to Serve the American People

The Problem
Several national studies have highlighted the problems caused by many types of medical errors, including under-use of accepted practices and over-use of certain treatments. These studies have been widely published in medical journals and show that medical errors are relatively common, causing thousands of injuries and deaths each year. Patient safety issues can also include prescription or medication errors and unnecessary procedures, tests and surgeries that result in patients undergoing sometimes risky procedures with no obvious benefit. In addition, treatments are sometimes underutilized, resulting in patients not receiving necessary care, such as regular treatment to control chronic conditions.

Our Solution
Patient safety has always been an integral part of Health Plan of Nevada's (HPN) commitment to arrange the best possible health care for its members. In 2000, HPN created an active Patient Safety Taskforce, chaired by HPN's medical director certified in occupational health and safety programs. The multi-discipline, multi-departmental taskforce serves as an advisory body to the HPN Quality Improvement Committee and includes a professional safety consultant, physicians, nurses, pharmacists and health plan administrators. The taskforce works to identify strategies and implement opportunities designed to maximize a safe health care environment and minimize the chance for medical errors.

Our Initiatives
HPN continues to develop and implement new strategies to strengthen the commitment to patient safety. Each initiative is designed with a specific goal in mind to maximize patient safety and minimize medical errors. Initiatives to enhance members' safety include:

• Electronic Prescriptions
  Computerized handheld devices in specific provider settings allow the provider to write electronic prescriptions for patients. The device automatically alerts the provider of the patient's medication allergies and notifies the provider of duplicate prescriptions that may have been written by a different provider. The device also transmits the prescription electronically directly to the pharmacy.

  Expected Outcomes:
  Reduced prescription errors due to misinterpretation of providers' handwriting by pharmacists
  Reduced errors due to patient allergies or duplicate drugs

  Measures of Success:
  Less medication errors due to incorrect dose or directions
  Less emergency room visits and hospitalizations

• Health Journal for Members
  Comprehensive journals for members are provided to record family medical history, surgeries, diagnoses, cholesterol, blood glucose level, etc. The journal also includes a section for detailed medication information, including dosage, purpose, etc.

  Expected Outcomes:
  Improved accuracy of information given by our patients to health care providers in the clinical, hospital or emergency setting

  Measures of Success:
  Less confusion on past medical history and minimal delays in obtaining medical treatment

• Virtual Library Resources for Practitioners and Nurses
  An electronic medical library allows practitioners and nurses to cross search more than 25 medical and drug textbooks. This resource provides instantaneous medical reference information to supplement clinical diagnosis and treatments.

  Expected Outcomes:
  More knowledgeable providers and nurses
  Up-to-date evaluation and treatment of medical conditions with improved diagnosis strategies

  Measures of Success:
  Improved clinical outcomes
  Improved use of preferred diagnostic tests

• Clinical Reference Advisory Series
  Patient instruction sheets for hundreds of conditions and diseases are available at the time of the clinical visit and can be personalized and printed by the practitioner with the patient's name and specific instructions.

  Expected Outcomes:
  Better education of our patients regarding their condition and follow up care instructions

  Measures of Success:
  Improved patient understanding of their condition and increased compliance with treatments

• Bioterrorism Training for Practitioners and Nurses
  Bioterrorism preparedness and awareness training is given to providers to help them better identify the types of medical conditions and symptoms that could potentially signal a bioterrorism event. The participants learn "what to do" in the unlikely event of a bioterrorism event. Early evaluation and identification is critical to help protect potential further spread of disease to other patients.

  Expected Outcomes:
  Increase practitioner's awareness of their role as an "early identifier" in a bioterrorist event
  Increase awareness of the social, ethical and legal obligations of reporting

  Measures of Success:
  Early identification and reporting

• HPN Provider's website
  Specifically designed to furnish current information needed by providers to make medical treatment decisions, the website includes patient safety information and lists existing and new technologies used to treat medical conditions. The website allows immediate access to providers to learn which new technologies have been approved for use.

  Expected Outcomes:
  Improved selection and use of appropriate new technologies for patient care

  Measures of Success:
  Reduction of unnecessary medical tests and procedures

• HPN Provider's Disease Management Guidelines
  HPN providers use written guidelines based on scientific medical evidence to treat various medical conditions. These guidelines assist the practitioner in selecting the best options for diagnostic testing and treatment to optimize patient care and minimize unnecessary or ineffective treatments.

  Expected Outcomes:
  Improved consistency of medical care
  Minimized use of ineffective tests and treatment

  Measures of Success:
  Reduced follow-up patient visits when initial treatment is less than effective
  Improved patient recovery times

• HPN Disease Management Reporting
  This system alerts providers about their high-, moderate- and low-risk patients with pediatric asthma, congestive heart failure, and diabetes. Providers are also informed of how their practice patterns compare to their peers, company and national guidelines and demonstrates trends in practice patterns. Working with the provider, HPN's case management staff can intervene, when appropriate, to connect patients with resources to help them manage their health, including educational classes.

  Expected Outcomes:
  Earlier identification of patients with chronic conditions requiring additional intervention
  More consistent medical care based on national norms and guidelines

  Measures of Success:
  Improved control of chronic medical conditions
  Better education for patients

• BioMedical Equipment Maintenance
  Medical equipment requires continuous maintenance to insure it is working properly, not hazardous to the user or patient, and gives accurate results. HPN provides a full-time, certified technician to evaluate and service equipment in provider settings where specialized equipment is used.

  Expected Outcomes:
  Minimizes potential for injury due to equipment failure
  Reduces malfunctions of equipment and the need to repeat tests

  Measures of Success:
  More accurate test results leading to improved patient care efficiency

• Home Safety Checklist
  Ensuring home safety is an important component of an overall injury prevention program. HPN provides a home safety assessment checklist to reduce the risk for falls and other injuries. Specific safety concerns for children, the elderly and home disaster preparedness are also included. The checklist is available on HPN's website.

  Expected Outcomes:
  A safer home environment

  Measures of Success:
  Less injuries in the home

• Clinical Pharmacy Services
  HPN is proud of its integrated drug utilization review process. This system routinely reviews prescription medication use by patients and will send messages to pharmacies regarding duplicate therapy or when a drug dose might be too high or low. HPN clinical pharmacists regularly review medical charts for inappropriate utilization and are available to HPN providers as a resource for consultation. Our pharmacy staff also assists with patient education and stress the importance of understanding the purpose for prescribed medications, medication compliance, common side effects, and storage of medications.

  Expected Outcomes:
  Improved patient education about prescription medications
  Best and appropriate choices of medications by providers

  Measures of Success:
  Minimized prescription medication errors

Our Commitment

HPN's Patient Safety Taskforce will continue to explore and implement innovative ways
to promote a safe health care environment for its members.