A couple of years ago, a kidney transplant patient left Hennepin County Medical Center with instructions for the wrong dose of antibiotics. Another patient, who was treated for a pulmonary embolism, was discharged without a needed blood thinner.
Eventually, the staff discovered the mistakes when the patients bounced right back to the hospital.
But it made Bruce Thompson, the hospital's pharmacy services director, wonder how often that kind of mix-up happened.
So he and his colleagues decided to do a spot-check of 37 patients who were discharged from the hospital to nursing homes over three months in 2008 and 2009.
The rate of medication errors: 92 percent. "It was alarming," he said. Only three of the 37 cases were problem-free.
The most common problems: Hospital physicians had prescribed the wrong doses, duplicate medications or omitted medications. Nearly a third were considered "likely harmful."
As a result, the hospital assigned pharmacists to check the discharge orders before patients are released. Now, if they spot a mistake, they contact the physician and straighten it out.
In nine months, the error rate dropped to "essentially 0 percent," according to the hospital's own study. And that, in turn, cut the 30-day readmission rate -- the number of patients bouncing back -- in the hospital in half, to a little more than 5 percent.
The results were so dramatic that the Institute for Safe Medication Practices gave its 13th annual "Cheers Award" to Hennepin County Medical Center. The award, presented in December, honors "excellence in the prevention" of medication errors.
Already, HCMC has had calls from hospitals around the country to ask about its success.
The project worked so well, Thompson said, that some doctors now call the pharmacist before they write the discharge orders. "They'll page the pharmacy and say, 'Bruce, come on over and work with me.'"