Little room for error. Bill protecting providers that report medical errors passes House, but hopes dim on road to Senate.
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Disclosure↗
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Harmful medication errors in children: a 5-year analysis of data from the USP's MEDMARX program.
Harmful pediatric medication errors are common in hospitals and health systems. Understanding what products are involved in these errors is important in the prevention of future errors. We used data from a voluntary medication error reporting system (MEDMARX) and identified 816 harmful outcomes involving 242 medications during a 5-year period. Eleven medications accounted for more than one third of reported errors (n = 261 or 34.5%). Wrong dosing and omission errors were common and were associated with therapeutic classes such as opioid analgesics (e.g., morphine and fentanyl), antimicrobial agents (e.g., vancomycin and gentamicin), and antidiabetic agents (e.g., insulin). Older commonly used agents still resulted in a substantial number of harmful pediatric medication errors and should be included in the focus of patient safety activities.
Adverse Drug Reaction Reporting Systems↗
Characteristics of medication errors made by students during the administration phase: a descriptive study.
Faculty concentrate on teaching nursing students about safe medication administration practices and on challenging them to develop skills for calculating drug dose and intravenous flow rate problems. In spite of these efforts, students make medication errors and little is known about the attributes of these errors. Therefore, this descriptive, retrospective, secondary analysis study examined the characteristics of medication errors made by nursing students during the administration phase of the medication use process as reported to the MEDMARX, a database operated by the United States Pharmacopeia through the Patient Safety Program. Fewer than 3% of 1,305 student-made medication errors occurring in the administration process resulted in patient harm. Most were omission errors, followed by errors of giving the wrong dose (amount) of a drug. The most prevalent cause of the errors was students' performance deficits, whereas inexperience and distractions were leading contributing factors. The antimicrobial therapeutic class of drugs and the 10 subcategories within this class were the most commonly reported medications involved. Insulin was the highest-frequency single medication reported. Overall, this study shows that students' administration errors may be more frequent than suspected. Faculty might consider curriculum revisions that incorporate medication use safety throughout each course in nursing major courses.
Adverse Drug Reaction Reporting Systems↗
The errors of error testing: potential liability issues for medication error testing of pharmaceutical trademarks under U.S. law.
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Drug Approval↗
Medication errors in nursing homes and small hospitals.
An observation method for measuring the rate of medication errors, which can be used as an outcome indicator of a medication system's quality, was evaluated in a national sample of long-term care facilities (LTCFs) and small hospitals. Trained nurse and pharmacist observers observed nurses administer medications during the three-hour period surrounding the peak medication workload on one day in national sample of 58 LTCFs and 10 hospitals. Opportunity-for-errors (OE), defined as the total number of doses ordered plus the unauthorized doses given, were counted, as well as all medication errors. The error rate was calculated as the proportion of errors in total OEs. The reliability of the method was evaluated on seven days by comparing the results of a researcher and observer, who were observing the same nurse. The mean-medication-error rate was 12.2 and 11.0% in the LTCFs and hospitals studied, respectively. Three LTCFs and four hospitals had error rates of zero. Only 31% of the LTCFs and 40% of the hospitals would pass a medication-error limit standard of 6%. The authors concluded that the observation method was promising. Recommendations for further study included: (1) implementation of a one-year project to evaluate observer efficiency after becoming proficient with the method, (2) improvement of the reliability measure, and (3) examination of the relationship of medication errors with structure and process variables.
Hospital Bed Capacity, 100 to 299↗
Combatting medication errors in home health.
Home care patients are vulnerable to medication errors. Until recently, however, little was done to find out how many or what types of errors were occurring. A 2001 study shows that nearly one out of three elderly home care patients has a potential medication error. The good news is that a simple intervention can be implemented by home care agencies to reduce this daunting statistic.
Aged↗
Role of computerized physician order entry systems in facilitating medication errors.
CONTEXT: Hospital computerized physician order entry (CPOE) systems are widely regarded as the technical solution to medication ordering errors, the largest identified source of preventable hospital medical error. Published studies report that CPOE reduces medication errors up to 81%. Few researchers, however, have focused on the existence or types of medication errors facilitated by CPOE. OBJECTIVE: To identify and quantify the role of CPOE in facilitating prescription error risks. DESIGN, SETTING, AND PARTICIPANTS: We performed a qualitative and quantitative study of house staff interaction with a CPOE system at a tertiary-care teaching hospital (2002-2004). We surveyed house staff (N = 261; 88% of CPOE users); conducted 5 focus groups and 32 intensive one-on-one interviews with house staff, information technology leaders, pharmacy leaders, attending physicians, and nurses; shadowed house staff and nurses; and observed them using CPOE. Participants included house staff, nurses, and hospital leaders. MAIN OUTCOME MEASURE: Examples of medication errors caused or exacerbated by the CPOE system. RESULTS: We found that a widely used CPOE system facilitated 22 types of medication error risks. Examples include fragmented CPOE displays that prevent a coherent view of patients' medications, pharmacy inventory displays mistaken for dosage guidelines, ignored antibiotic renewal notices placed on paper charts rather than in the CPOE system, separation of functions that facilitate double dosing and incompatible orders, and inflexible ordering formats generating wrong orders. Three quarters of the house staff reported observing each of these error risks, indicating that they occur weekly or more often. Use of multiple qualitative and survey methods identified and quantified error risks not previously considered, offering many opportunities for error reduction. CONCLUSIONS: In this study, we found that a leading CPOE system often facilitated medication error risks, with many reported to occur frequently. As CPOE systems are implemented, clinicians and hospitals must attend to errors that these systems cause in addition to errors that they prevent.
Clinical Pharmacy Information Systems↗
Evaluation of reported medication errors before and after implementation of computerized practitioner order entry.
While a major objective of CPOE is to reduce medication errors, its introduction is a major system change that may result in unintended outcomes. Monitoring voluntarily-reported medication errors in a university setting was used to identify the impact of initial CPOE implementation on medical-surgical and intensive care units. A retrospective trend analysis was used to compare errors one year before and six months after implementation. Total error reports increased post-CPOE but the level of patient harm related to those errors decreased. Numerous modifications were made to the system and the implementation process. The study supports the notion that CPOE configuration and implementation influences the risk of medication errors. Implementation teams should incorporate monitoring medication errors into project plans and expect to make ongoing changes to continually support the design of a safer care delivery environment.
Diffusion of Innovation↗
[Medical errors in the continuous improvement of quality].
The increase in medical errors during the last four decades of past centuries can be attributed to several causes: the human fallibility always present, concern in quality and continuity of physician-patient relationship and to the increased advance in technology innovation. These errors attract the attention of Agencies and Organizations involved in Healthcare Quality. From the work of these a series of recommendations were issued for the prevention of medical errors. The action level is a systemic one, due to the characteristic of the healthcare services.
Humans↗
Identifying and addressing medical errors in pain mismanagement.
BACKGROUND: There is strong evidence in the pain management literature that undertreatment of pain is pervasive despite several approaches, including use of national guidelines, to completely correct the problem. Although the concept of medical errors has primarily been concerned with adverse events, it is not unreasonable that mismanagement of pain could also be classified as a medical error. ERRORS OF PAIN MANAGEMENT: Error types can be classified as errors in assessment and documentation, errors in treatment and management, and errors in patient education. Within each of these categories, errors may be skill-, rule-, and/or knowledge-based, as suggested by evidence of mismanagement in various aspects of the pain management process as found in the literature. An examination of the root causes of medical errors may be used to detect system failures. At least ten steps can be identified in the process of pain management in the acute care setting, starting with admission, and errors can potentially occur at any step. A redesigned system could help improve error rates by incorporating use of skills, rules, and knowledge for effective management. CONCLUSION: A new approach to the unsolved problem of pain management in acute care settings is proposed; this approach uses the concept of mismanagement as a medical error.
Attitude of Health Personnel↗
Risk managers looking to EMR systems for proactive reduction of medical errors.
An initiative combining risk management and electronic medical records (EMRs) at MedStar Health, Columbia, MD, is expected to reduce medical errors and cut malpractice losses by an average of approximately $2 million a year.
Actuarial Analysis↗
Medical errors related to discontinuity of care from an inpatient to an outpatient setting.
OBJECTIVE: To determine the prevalence of medical errors related to the discontinuity of care from an inpatient to an outpatient setting, and to determine if there is an association between these medical errors and adverse outcomes. PATIENTS: Eighty-six patients who had been hospitalized on the medicine service at a large academic medical center and who were subsequently seen by their primary care physicians at the affiliated outpatient practice within 2 months after discharge. DESIGN: Each patient's inpatient and outpatient medical record was reviewed for the presence of 3 types of errors related to the discontinuity of care from the inpatient to the outpatient setting: medication continuity errors, test follow-up errors, and work-up errors. MEASUREMENTS: Rehospitalizations within 3 months after the initial postdischarge outpatient primary care visit. MAIN RESULTS: Forty-nine percent of patients experienced at least 1 medical error. Patients with a work-up error were 6.2 times (95%confidence interval [95% CI], 1.3 to 30.3) more likely to be rehospitalized within 3 months after the first outpatient visit. We did not find a statistically significant association between medication continuity errors (odds ratio [OR], 2.5; 95%CI, 0.7 to 8.8) and test follow-up errors (OR, 2.4; 95%CI, 0.3 to 17.1) with rehospitalizations. CONCLUSION: We conclude that the prevalence of medical errors related to the discontinuity of care from the inpatient to the outpatient setting is high and may be associated with an increased risk of rehospitalization.
Ambulatory Care↗
How a system for reporting medical errors can and cannot improve patient safety.
The Institute of Medicine has recommended systems for reporting medical errors. This article discusses the necessary components of patient safety databases, steps for implementing patient safety reporting systems, what systems can do, what they cannot do, and motivations for physician participation. An ideal system captures adverse events, when care harms patients, and near misses, when errors occur without any harm. Near misses signal system weaknesses and, because harm did not occur, may provide insight into solutions. With an integrated system, medical errors can be linked to patient and team characteristics. Confidentiality and ease of use are important incentives in reporting. Confidentiality is preferred to anonymity to allow follow-up. Analysis and feedback are critical. Reporting systems need to be linked to organizational leaders who can act on the conclusions of reports. The use of statistics is limited by the absence of reliable numerators and denominators. Solutions should focus on changing the cultural environment. Patient safety reporting systems can help bring to light, monitor, and correct systems of care that produces medical errors. They are useful components of the patient safety and quality improvement initiatives of healthcare systems and they warrant involvement by physicians.
Guidelines as Topic↗
Follow-up study of medication errors reported to the vaccine adverse event reporting system (VAERS).
BACKGROUND: A study was done to determine if the apparent medication errors found in the Vaccine Adverse Event Reporting System (VAERS) database are true errors, and if true errors are found, to determine what corrective action was taken. Furthermore, if a true error did not occur, we wanted to determine at what point the misinformation was entered into the system. METHODS: The VAERS database was searched for reports received between July 1, 2001 and June 30, 2002 which had either been classified as "error" or the word "error" appeared in the text of the report. The database was also searched for reports which indicated that the measles-mumps-rubella (MMR), diphtheria-tetanus-pertussis (DTP), diphtheria-tetanus-acellular pertussis (DTaP) or diphtheria-tetanus-pertussis-haemophilus (DTPH) vaccinations had been administered at an age outside of the usual recommendation. RESULTS: A total of 119 reports of possible errors were found. Follow-up was successful in 102 (86%) cases. Additional information obtained showed that 26 cases were actual medication errors. Seventy-six cases were not actual medication errors; 9 cases were physician decisions, 37 cases were data entry errors and 30 cases were reporter errors. CONCLUSION: The nature of the actual errors was similar to those reported previously; wrong inoculum, improper interval, wrong route of administration, and overdose. Many errors could have been prevented by more attention to detail. Remedial action usually consisted of retraining. The new requirement that all medications be barcoded, purchasing products from different manufacturers and segregation of vials may help prevent vial confusion.
Adolescent↗
Effect of computerized physician order entry and a team intervention on prevention of serious medication errors.
CONTEXT: Adverse drug events (ADEs) are a significant and costly cause of injury during hospitalization. OBJECTIVES: To evaluate the efficacy of 2 interventions for preventing nonintercepted serious medication errors, defined as those that either resulted in or had potential to result in an ADE and were not intercepted before reaching the patient. DESIGN: Before-after comparison between phase 1 (baseline) and phase 2 (after intervention was implemented) and, within phase 2, a randomized comparison between physician computer order entry (POE) and the combination of POE plus a team intervention. SETTING: Large tertiary care hospital. PARTICIPANTS: For the comparison of phase 1 and 2, all patients admitted to a stratified random sample of 6 medical and surgical units in a tertiary care hospital over a 6-month period, and for the randomized comparison during phase 2, all patients admitted to the same units and 2 randomly selected additional units over a subsequent 9-month period. INTERVENTIONS: A physician computer order entry system (POE) for all units and a team-based intervention that included changing the role of pharmacists, implemented for half the units. MAIN OUTCOME MEASURE: Nonintercepted serious medication errors. RESULTS: Comparing identical units between phases 1 and 2, nonintercepted serious medication errors decreased 55%, from 10.7 events per 1000 patient-days to 4.86 events per 1000 (P=.01). The decline occurred for all stages of the medication-use process. Preventable ADEs declined 17% from 4.69 to 3.88 (P=.37), while nonintercepted potential ADEs declined 84% from 5.99 to 0.98 per 1000 patient-days (P=.002). When POE-only was compared with the POE plus team intervention combined, the team intervention conferred no additional benefit over POE. CONCLUSIONS: Physician computer order entry decreased the rate of nonintercepted serious medication errors by more than half, although this decrease was larger for potential ADEs than for errors that actually resulted in an ADE.
Clinical Pharmacy Information Systems↗
CM can play critical role in reducing medical errors.
These days, virtually every hospital in the country is actively engaged in finding ways to reduce medical errors. And now, many are catching on to the fact that case management can play a pivotal role in this pursuit. Indeed, the role of case managers in reducing medical errors is critical, says Michelle Gofney, director of case management at Deborah Heart and Lung Center, a 161-bed hospital with a full-service ambulatory care center in Mills, NJ. 'Case managers are the primary specialty voice to reduce medication errors,' explains Gofney. She says that is because case managers alone look at the patient's medical care through the physician's eyes and the nurse's eyes as well as every ancillary department in the hospital.
Case Management↗
Medical error and human factors engineering: where are we now?
The goal of human factors engineering is to optimize the relationship between humans and systems by studying human behavior, abilities, and limitations and using this knowledge to design systems for safe and effective human use. With the assumption that the human component of any system will inevitably produce errors, human factors engineers design systems and human/machine interfaces that are robust enough to reduce error rates and the effect of the inevitable error within the system. In this article, we review the extent and nature of medical error and then discuss human factors engineering tools that have potential applicability. These tools include taxonomies of human and system error and error data collection and analysis methods. Finally, we describe studies that have examined medical error, and on the basis of these studies, present conclusions about how human factors engineering can significantly reduce medical errors and their effects.
Ergonomics↗
How surgeons disclose medical errors to patients: a study using standardized patients.
BACKGROUND: Calls are increasing for physicians to disclose harmful medical errors to patients, but little is known about how physicians perform this challenging task. For surgeons, communication about errors is particularly important since surgical errors can have devastating consequences. Our objective was to explore how surgeons disclose medical errors using standardized patients. METHODS: Thirty academic surgeons participated in the study. Each surgeon discussed 2 of 3 error scenarios (wrong-side lumpectomy, retained surgical sponge, and hyperkalemia-induced arrhythmia) with standardized patients, yielding a total of 60 encounters. Each encounter was scored by using a scale developed to rate 5 communication elements of effective error disclosure. Half of the encounters took place face-to-face; the remainder occurred by videoconference. RESULTS: Surgeons were rated highest on their ability to explain the medical facts about the error (mean scores for the 3 scenarios ranged from 3.93 to 4.20; maximum possible score, 5). Surgeons used the word error or mistake in only 57% of disclosure conversations, took responsibility for the error in 65% of encounters, and offered a verbal apology in 47%. Surgeons acknowledged or validated patients' emotions in 55% of scenarios. Eight percent discussed how similar errors would be prevented, and 20% offered a second opinion or transfer of care to another surgeon. CONCLUSIONS: The patient safety movement calls for disclosure of medical errors, but significant gaps exist between how surgeons disclose errors and patient preferences. Programs should be developed to teach surgeons how to communicate more effectively with patients about errors.
Communication↗