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PubMed2001

Medical errors in surgery.

Researchers at the Institute of Medicine have reported a staggering number of medical errors, that is, adverse effects as a result of treatment, in healthcare in America. This article argues against a no-faults systems view as a corrective for these events and calls us instead to trust the motivations of providers and the peer review process to bring about the needed cultural revolution. It sees healthcare as an honorable profession rather than an off-the-shelf commodity, and calls on providers to be courageous leaders who make safety their priority.

Confidentiality↗
PubMed2005

Results of a survey on medical error reporting systems in Korean hospitals.

BACKGROUND: Recent data suggest that medical injuries, or adverse events, represent an important international problem, and that many are caused by errors. Spontaneous reporting is the main tool used to detect errors and adverse events in most countries, and reporting systems are believed to be important for improving patient safety. Increasingly, such reporting can be done using information systems, and information systems are widely used in Korea. However, few data are available regarding the use of electronic medical error reporting systems in Korea. OBJECTIVES: The objectives of this study were to investigate the present status of reporting system of Korean hospitals, and to compare the current status of medical error reporting systems with that of other health information sub systems. METHODS: The chairs of nursing departments of all 283 hospitals nationwide with more than 100 beds were surveyed using a structured questionnaire. The response rate was 35%. In addition, two reports on the national use of health information systems in Korea from 1999 and 2003 were analyzed. RESULTS: Among reporting hospitals (n=99), medical errors were reported on paper in 75 hospitals (77%), verbally in 30 hospitals (30%), using word processing in 13 hospitals (13%), and using the hospital information system in only three hospitals (3%). In contrast, there was widespread and increasing use of health information technology (HIT) in areas such as medication administration, inpatient and outpatient order entry, and radiology. CONCLUSIONS: While HIT is increasingly widely used in Korea in many areas, it is not being used for error reporting. Increasing the use of electronic reporting systems, and systemically evaluating the medical errors and adverse events reported, represent essential steps for reducing systemic errors and improving patient safety.

Health Care Surveys↗
PubMed2002

Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis.

When a patient with multiple, complicated conditions is admitted to a hospital and risky procedures are performed that result in adverse outcomes, the difficulties inherent in determining whether and when a preventable medical error has occurred must be addressed. This article analyzes the case of a 40-year-old woman with a history of chronic aortic dissection and pericardial effusion who was admitted to a teaching hospital with unilateral swelling of her left breast and arm accompanied by dyspnea. During her hospitalization, the patient developed multiple complications from the diagnostic and therapeutic procedures that were performed. The authors argue that this case illustrates some limitations of routinely undertaking time-consuming and costly reviews, or "root-cause analyses," as a patient safety strategy when they are unlikely to reveal remediable "errors" or to suggest better systems of care that will prevent errors. The ability to establish causality through post hoc reviews is the linchpin in the recommendation for widespread adoption of error reporting and reviews. When causality is not established, it is impossible to know whether any changes adopted as a result of the reviews will be effective. This case, in which the causal pathways to the adverse events are very uncertain, may be much more typical than the egregious errors featured in a classic root-cause analysis. The authors recommend that the relative merits of this approach to patient safety be compared with other proven, cost-effective interventions to improve quality, such as appropriate treatment of myocardial infarction or depression, before scarce resources and enormous human capital are allocated for widespread implementation.

Adult↗
PubMed1999

How case managers can help reduce medical errors.

Although mistakes are inevitable, even in the best-run organizations, the tools used for care coordination--such as clinical pathways, standing order sets, algorithms, and other "point of care" reminders--are among the most important weapons in the fight against medical errors in hospitals. For example, establish maximum doses for high-risk drugs, and incorporate these criteria into pathways or standing orders. Preprinted order sets and protocols allow staff to focus their attention on relevant patient care issues, rather than spending time rewriting orders and possibly introducing errors into the system. Case managers can be particularly effective in helping other caregivers catch and correct mistakes before the patient is harmed.

Case Management↗
PubMed2006

Automated medication error studies with audit supplementation were effectively designed and analyzed by time series.

BACKGROUND AND OBJECTIVE: To provide researchers with an efficient yet methodologically robust method to design and analyze studies of the effectiveness of quality improvement interventions targeted at medical errors. METHODS: An interrupted time-series design was chosen. Error rates of a preintervention observational period are compared to those of an intervention period (interrupted by a brief transitional period not used in the analysis). Potential errors are flagged by computerized analysis. The positive predictive value of this automated method is established by targeted expert review of random samples of monthly admissions with flagged errors. The lengths of the preintervention and intervention observational periods and number of audits per month are determined via power and type I error analysis. The setting was a future study of electronic alert systems for errors related to nephrotoxic agents in a medium-sized hospital. RESULTS: Based on these methods, a study was deemed feasible to be conducted over a 38-month period, auditing 40 potential errors per month. CONCLUSION: A logistic monthly error process model with independent variables (1) time in months (same slope pre vs. postintervention), and (2) a discrete jump postintervention to assess the effect size, offers a flexible, easy-to-interpret way to attack this problem.

Decision Support Systems, Clinical↗
PubMed2002

Cut medication errors in half with ED pharmacist.

Using a dedicated pharmacist in the ED can drastically cut costs and medication errors. The pharmacist is a valuable resource for physicians, who can obtain current information about complex drug interactions. Nurses receive regular inservices about medication administration. Monthly costs were cut by $61,000 due to more appropriate utilization of medications.

Efficiency, Organizational↗
PubMed2005

The safety of inpatient pediatrics: preventing medical errors and injuries among hospitalized children.

This article explores the current state of knowledge about the safety of hospitalized patients in general and patients in pediatric settings in particular. It discusses approaches to evaluating patient safety and reviews the current literature on adverse events and errors in hospitals. The article also discusses strategies proven effective in reducing medical errors and some of the barriers to implementing these strategies that must be overcome.

Child↗
PubMed2005

Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit.

INTRODUCTION: The study aimed to compare the impact of computerised physician order entry (CPOE) without decision support with hand-written prescribing (HWP) on the frequency, type and outcome of medication errors (MEs) in the intensive care unit. METHODS: Details of MEs were collected before, and at several time points after, the change from HWP to CPOE. The study was conducted in a London teaching hospital's 22-bedded general ICU. The sampling periods were 28 weeks before and 2, 10, 25 and 37 weeks after introduction of CPOE. The unit pharmacist prospectively recorded details of MEs and the total number of drugs prescribed daily during the data collection periods, during the course of his normal chart review. RESULTS: The total proportion of MEs was significantly lower with CPOE (117 errors from 2429 prescriptions, 4.8%) than with HWP (69 errors from 1036 prescriptions, 6.7%) (p < 0.04). The proportion of errors reduced with time following the introduction of CPOE (p < 0.001). Two errors with CPOE led to patient harm requiring an increase in length of stay and, if administered, three prescriptions with CPOE could potentially have led to permanent harm or death. Differences in the types of error between systems were noted. There was a reduction in major/moderate patient outcomes with CPOE when non-intercepted and intercepted errors were combined (p = 0.01). The mean baseline APACHE II score did not differ significantly between the HWP and the CPOE periods (19.4 versus 20.0, respectively, p = 0.71). CONCLUSION: Introduction of CPOE was associated with a reduction in the proportion of MEs and an improvement in the overall patient outcome score (if intercepted errors were included). Moderate and major errors, however, remain a significant concern with CPOE.

Chi-Square Distribution↗
PubMed1998

Prevention of medication errors in the pediatric inpatient setting. American Academy of Pediatrics. Committee on Drugs and Committee on Hospital Care.

Medication errors that occur on a pediatric medical/surgical inpatient care unit are usually avoidable. Several steps are recommended to reduce these errors, beginning with the physician and including every member of the health care team. Pediatricians should help hospitals develop effective programs for safely providing treatment with medications to hospitalized children.

Child↗