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Patient Safety Awareness Week: March 7-11, 2005

Patient Safety Awareness Fair
March 8 and 9:
• Nelson Lobby, 6:30 a.m. to 9 a.m., 11 a.m. to 2 p.m., 5 p.m. to 8 p.m.
• Weinberg Lobby, 7 a.m. to 10 a.m., noon to 4:30 p.m.
March 9 and 10:
• JHOC 1, 7 a.m. to 9:30 a.m., 11 a.m. to 1 p.m., 3 p.m. to 5:30 p.m.

Games, videos, posters, literature, information booths and prizes.*



A Matter of Quick Recall

Keeping track is a breeze these days now that RASMAS organizes myriad product recalls. Linda Smith, left, and “zone coordinator” Dee Jenkins, a supervisor in Materials Management, pictured here in Central Stores.

A tiny guide wire used to implant a pacemaker is found to be at risk of fracturing. Liquid-filled cotton swabs leak while in storage. “Solid foreign matter” is found lodged within trach tubes. A particular lot number of Lupron, a drug commonly used for prostate cancer, contains caked powder.

Day in and day out, findings like these involving medical equipment, supplies and drugs arrive at hospitals in the form of product bulletins, alerts and recalls. Staying abreast, particularly in a vast medical enterprise like this, is no easy task. But it is key, because these items are potentially dangerous to patients. Getting them off hospital shelves before they cause harm is of the utmost importance.

Now, a revolutionary patient safety service currently in use throughout the Health System has made that task more efficient and made patients safer, too. The Risk and Safety Management Alert System, or RASMAS, searches databases such as the FDA’s enforcement report, culls product notices, separates them by type and geographic location, and speeds them to subscribing health care organizations.

Developed here by the Center for Innovation in Quality Patient Care in concert with a nonprofit research and engineering company in northern Virginia called Mitretek, RASMAS has been in production since early 2004. It has since been adopted by about 100 subscribing health care organizations across the country. In December, it received the Best New Patient Safety and Disclosures Award from the Health Care Research and Innovations Congress.

“It’s cut the time I do recalls in half,” says Linda Smith of Materials Management. Smith is recall coordinator for supplies. Under her purview fall practically all the medical supplies used in Hopkins Hospital’s ORs, clinics and labs. Her domain also encompasses items like hardware and software, radiology products, blood, children’s toys—everything, in short, except drugs, overseen by Shirley Geize, assistant director of purchasing for Pharmacy, and biomedical devices, handled by Roy Shipley, associate clinical engineer.

With RASMAS, Smith is notified of product bulletins, alerts or recalls via e-mail. She checks Hopkins’ own database to make sure the potentially defective item exists here, verifying vendor, catalogue number and lot number. If she comes up with a match, she immediately forwards the e-mail to her fleet of “responders,” specially designated employees who work in various departments throughout the hospital. With her “zone coordinators,” based in the Central Storeroom, they are responsible for yanking the item off the shelves.

Things were not always thus. In the past, these three recall coordinators would have to wade through 20- and 30-page reports to see if any of their products were involved. “Now, it’s all online, and we’re notified automatically,” says Shipley. “Plus, we have an electronic record of what we’ve done, instead of file after file of handwritten notes.”

That record is particularly helpful when regulators pay a call. Should they ask Shipley how he resolved a problem involving, say, a certain ventilator, he could easily get the answer. “Previously, we might have to spend days hunting down all the paperwork,” says Wayne Sparkes, RASMAS project manager in the Center for Innovation. “Now, in minutes, we electronically pull down the alert and the tracking system record and tell regulators what we did at every step.”

Sparkes hopes RASMAS will be integrated into other internal electronic systems so that it gives an accurate inventory of the product and where it’s located. “That would be the total package.”

Anne Bennett Swingle



Johns Hopkins Medicine

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