Medical Errors

Reducing Medical Errors

AGENCIES CONCERNED WITH SAFER MEDICAL CARE:
      AHRQ   U.S. Agency for Healthcare Research and Quality (AHRQ) .
           WebM&M: Morbidity & Mortality Rounds . Health Care: Medical Errors & Patient Safety e . .
      Institute of Medicine - (National Academy of Sciences) - The sponsors of Dr. Leape's 1991 report on medical errors discusses approaches to safer health care.
       Risk Management Foundation
      The Institute For Safe Medication Practices (ISMP) .
      Joint Commission on Accreditation of Healthcare Organizations .
      United States Pharmacopeial Convention Inc. U.SP. has been setting standards for drugs since 1820 .
      MedWatch at U.S. Food & Drug Administration

ARTICLES:

Improving Safety with Information Technology-    DW Bates, M.D., and A A Gawande, M.D., M.P.H.
           New Engl J Med 2003 June 19 348(25):2526-34
      This important article identifies areas in which readily availble technology can reduce errors by as much as 80%.
No less important are the 59 references discussing ways in which technology can reduce medical errors.

Residents' Suggestions for Reducing Errors in Teaching Hospitals
NEJM 348(9):851-855 February 27, 2003 K.G.M. Volpp, M.D., Ph.D. D. Grande, M.D.
The authors identify 8 areas of concern and discuss changes that are necessary to avoid needess patient morbidity and morality.

Mammogram Team Learns From Its Errors
     New York Times       June 28, 2002
    Kaiser Permanente radiologist improves accuracy by firing doctors who have high error rates
             - the result was 1/3 fewer cancers missed.

Report : National health-Care System Woefully Lacking; Tangled Maze: Institute Recommends an Overhaul to Bring 21st-Century Care to Patients
Telegraph Herald (Dubuque, IA); March 2, 2001, Pg. a2
U.S. scientists have developed highly effective treatments for many diseases but too many Americans get inadequate, outdated or even unsafe therapy instead because the nation's health-care system is a tangled maze, the Institute of Medicine said in a scathing report Thursday.

Reporting and Prevention of Medical Errors
Prepared Statement of Lucian L. Leape, M.D. Harvard School of Public Health Subject Before the Senate Committee on Health, Education, Labor and Pensions; May 24, 2001

Reporting medical errors and adverse events; Research Corner.
AORN Journal April 1, 2002 ; JCAHO call for Safety

VA tries to learn from its mistakes; Hospitals focusing on errors, not blame, to revolutionize care
The Baltimore Sun December 22, 2001; Baltimore VA reports progress in decreasing medical errors.

Harvard Prof Urges Hospitals to Spot, Curb Bad Doctors
The Boston Herald March 30, 2001
"Every hospital has doctors whose performance is a concern," said Dr. Lucian L. Leape, professor at the
Harvard School of Public Health. "We do have problem doctors. Everybody has witnessed it. But everybody insists it is someone else's problem. It's a major issue and hospitals have to take the primary responsibility."

Hospital Patient Safety Information Gives Consumers the Power To Make More Informed Health Care Choices;
PR Newswire January 17, 2002 , Thursday
Leapfrog Group Unveils First Results of Unique Survey: Initial Focus on Six Regions including Atlanta, California, East Tennessee, Minnesota, St Louis,
and Seattle-Tacoma-Everett http://www.leapfroggroup.org

Curtail Health Workers' Hours to Save Lives, Senators Urged
Chicago Tribune, February 2, 2000, Pg. 7
An expert on medical mistakes, which kill as many as 98,000 Americans every year, called last week for limiting the notoriously long hours medical personnel work.

10 Common Prescribing Errors Consultant; 41(6) p. 766 May 1, 2001
Sound-alike Drugs; Lack of Drug Knowledge; Dose Calculation Errors; Decimal Point Misplacement; Wrong Dosage Form;
Wrong Frequency; Use of Abbreviations; Drug Interactions; Renal Insufficiency; Incomplete Patient History

http://www.usp.org/reporting/review/qr66.pdf .1000 name pairs that have been confused on prescriptions have been identified

Pharmacist participation on physician rounds and adverse drug events in the intensive care unit.
Leape LL, et al. JAMA. 1999; 282(3):267-270. In group with Senior pharmacist participating in ICU rounds, The rate of preventable ordering Adverse Drug Events decreased by 66% from 10.4 per 1000 patient-days before the intervention to 3.5 after the intervention.

Patient-safety awards abound , but do they represent real progress in the fight against medical errors, or are they just for show? Modern Healthcare; April 22, 2002, Monday
''Part of the initial step in making progress is understanding that there's a problem. Now we know there's a problem.''

Reducing Errors in Health Care: Translating Research Into Practice
How Errors Occur.Medication Errors .Surgical Errors .Diagnostic Inaccuracies .System Failures
Improving Patient Safety. Adverse Event Monitoring .Computer-Reminders .Protocols .Promoting Safety .
AHRQ Publication No. 00-PO58 April, 2000
Nat'l Academy Press, Crossing the Quality Chasm: (2001) .

In search of safety : Nursing Economics January 1, 2002 http://www.premierinc.com/

Building an Electronic Network of Care; Group Seeks to Cut Medical Errors by Sharing Information While Guarding Privacy Washington Post, December 12, 2001

State awarded $ 4.5m to fight medical errors.
The Boston Herald October 30, 2001; NEWS; Pg. 016
The three-year project will seek more information about how errors occur and about how patients, doctors, hospital officials and others can make the system safer.

Paths to reducing medical injury: professional liability and discipline vs. patient safety -- and the need for a third way. Journal of Law, Medicine & Ethics September 22, 2001; Pg. 369

Health Care Quality and How to Achieve It
Comments by Kenneth Shine, M.D. President of the Institue of Medicine

Oops, Wrong Patient: Journal Takes On Medical Mistakes
The New York Times June 18, 2002
The patient had been on the operating table for an hour. Doctors had made an incision in her groin, punctured an artery, threaded in a tube and snaked it up into her heart. Now they were stimulating her heart electrically, to test for abnormal rhythms.
The phone rang: it was a doctor from another department. What, he asked, were they doing with his patient? There was nothing wrong with her heart.
Annals of Internal Medicine series highlights case reports of errors to focus on what can be done to reduce injuries.

To err is human : How to prevent medical errors. Patient Care June 15, 2001; Pg. 95

Links - Medical Errors and Preventing Medical Errors
      Preventing Medical Errors: Abstract from Nursing Learning Network course
       Home Study Educators - Preventing Medical Errors (50 Page PDF with annotations)
      New York Medical College Family Practice Residency - Guide for preventing medical errors (90 page PDF - LONG DOWNLOAD!)
      1999 Insitiute of Medicine report How the IOM concluded that from 44,000 to 98,000 die annually from medical errors
       Media Citations to the IOM Report

How Many Medical errors? .
What kind of errors?, Wrong Side Surgery, Not Following Guidelines, Reducing Errors,
Doctor Discipline