Articles on How to Reduce Medical Errors
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| Articles on How to Reduce Medical Errors The following are "leads" only, contact the publishers for full text. Comments, Suggestions? mailto:doctor-lawyer@md-jd.com |
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How Can Medical Errors be Reduced?
Web Sites of Agencies Concerned with Safer Medical
Care:
Institute of
Medicine - (National Academy of Sciences) - The sponsors of Dr. Leapes
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.
U.S. Agency for Healthcare
Research and Quality.
Kaiser Hospitals Implement Safeguards New Procedures at 2 Sites
Where Fatal Mistakes Occurred
San
Francisco Chronicle November 5, 2005
Kaiser Permanente hospitals in Santa Clara and San Jose
have instituted safeguards approved by the California Department of Health
Services to prevent future deaths from the kind of mistakes that recently
claimed the lives of a 12-year-old girl with pneumonia and a 21-year-old
man with lymphoma.
The hospital, Kaiser Permanente Santa Clara Medical Center,
now requires that two registered nurses write their initials on medication
bags before administering epinephrine and other "high-risk" drugs, and that
all such drugs be labeled with brightly colored stickers, according to Scott
Vivona, branch chief of Bay Area field operations for the state Department
of Health Services.
Officials from the state said the hospital, Kaiser Permanente
Santa Teresa Medical Center, has retrained its staff on the importance of
adhering to the "Five Rights of Medication Administration" -- right dose,
right medication, right time, right patient, right administration (oral,
intravenous, injection).
"In really safe systems, 'dikes' have been created around
the normal human frailties," he said, citing aircraft carriers and nuclear
power plants as examples. "We haven't done that in heath care."
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.
I. Technology:
- Since Paging interrupts patient care, implement develop a priority system.
- Use electronic ordering to avoid handwriting errors and to catch avoidable
drug-drug interactions and drug-patient contraindications.
- Use computerized sign out procedures to pass on critical patient information.
II. Improving the Work Environment
- Excessive work hours interferes with safe for patient care and effective
learning.
- Too many hours are wasted hust looking for charts; this needs to be standardized.
III. Changing the Academic Culture.
- If residents cannot report errors without fear of being judged, patients
can and will suffer and die. FN 1
- The “See one, do one, teach one” method of teaching procedures is a formula
for complications.
- The “teams” of doctors, nurses, etc. caring for patients need to coordinate
their activities in order to deliver proper care.
1. A. Wu et al.; Do house officers learn from their mistakes? JAMA 1265:2089-2094
(1991)
TOP Citations to IOM report
New York Times
June 28, 2002
Mammogram Team Learns From Its Errors
DENVER - Seven years ago, Dr. Kim A. Adcock started a revolution in mammography:
He decided to keep score.
Dr. Adcock had just become radiology chief at Kaiser
Permanente Colorado, and he was already hearing whispers of problems with
his staff. So he pored over the doctors' records, counted the cancers they
had missed and printed their batting averages in bar charts and graphs.
This was deeply controversial territory. To many doctors,
keeping score was yet another assault on their autonomy and prestige. It could
also, they warned, be dangerous: The statistics were tricky and easily twisted.
The malpractice lawyers would pounce. Worse still, if women knew how many
cancers their doctors had missed, they might avoid mammograms altogether.
When Dr. Adcock looked at the numbers, though, he saw
a promise of revelation, a fair and rigorous way to hold his mammography
doctors - and perhaps doctors in other specialties - accountable for their
work. That was what Americans were demanding from the health care system,
wasn't it?
So he pushed on. When he discovered that one doctor had
missed 10 cancers in the space of 18 months, he fired him. Over the next two
years, he fired two others who were missing more than their share of tumors.
He then reassigned eight doctors who were not reading enough films to stay
sharp - or for the data to show how sharp they were. "I had to assume they
might be dangerous," he explains.
The immediate result was sensational headlines and much
in-house angst. But today, Dr. Adcock's team is missing one-third fewer
cancers and has achieved what experts say is nearly as high a level of accuracy
as mammography can offer. "Every mammography program in the
country should be doing something like this," says Dr. Robert A. Smith,
the American Cancer Society's screening chief.
Very few do. In fact, what Dr. Adcock has created is a mirror
image of American mammography as usual - an industry that remains deeply troubled
10 years after Congress set out to clean it up through its own experiment
in medical regulation.
In fact, what Dr. Adcock has created is a mirror image of American mammography
as usual - an industry that remains deeply troubled 10 years after Congress
set out to clean it up through its own experiment in medical regulation.
TOP Citations to IOM report
Telegraph Herald (Dubuque, IA)
March 2, 2001, Friday
Report: National health-care system woefully lacking;
Tangled maze: Institute recommends an overhaul to bring 21st-century care
to patients
WASHINGTON (AP) - 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.
It recommends an urgent overhaul to bring 21st-century care to more patients,
and urges Congress to set aside $ 1 billion over the next three to five years
to spur programs that help.
Key to improvement is getting more doctors to follow scientific evidence
and making the health-care system respond more quickly to patients' needs
- even if they are sick at 2 a.m. or on the weekend.
TOP Citations to IOM report
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
TOP Citations to IOM report
Harvard Prof Urges Hospitals to Spot, Curb Bad
Doctors
The Boston Herald March 30, 2001
The "godfather" of the movement to reduce medical mistakes yesterday urged hospitals to identify problem doctors and take responsibility for making sure they don't harm patients.
"Every hospital has doctors whose performance is a concern," said Dr. Lucian L. Leape, a professor at the Harvard School of Public Health who has taken the lead in a growing movement that seeks to prevent medical errors.
"We do have problem doctors," he told a forum on patient safety sponsored by the Massachusetts Medical Society.
"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."
TOP Citations to IOM report
The New York Times
December 5, 1999, Sunday, Late Edition - Final
Ideas & Trends: Do No Harm;
Breaking Down Medicine's Culture of Silence
DR. MICHAEL LEONARD, an anesthesiologist and chief of surgery for Kaiser
Permanente in Denver, was operating on a cancer patient a few months ago
when he reached into a drawer for medicine. Inside were two vials, side by
side. Both had yellow labels. Both had yellow caps. One was a paralyzing
agent, which Dr. Leonard had correctly administered to keep the patient still
during the operation. The other was the reversal agent, which he needed next.
"I grabbed the wrong one," Dr. Leonard recalled. "I used the wrong drug."
It would have been easy for the doctor to keep quiet; the drug wore off
and the patient was not harmed. Instead, he talked -- to the surgeon and
scrub nurses, the patient's wife and the hospital pharmacist, who has since
relabeled the paralyzing agents with red stickers and put them in a separate
drawer. He also talked to his five partners, whose reaction unnerved him.
TOP Citations to IOM report
DEADLY ERRORS 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.
Health care should have safeguards similar to those that make sure
airlines, nuclear plants and other industries are
safe, Dr. Lucian Leape, a member of the Institute of Medicine panel that
reported the surprisingly high rate of deaths due to medical errors
last year, told a Senate subcommittee.
TOP Citations to IOM report
10 Common Prescribing Errors Consultant;
41(6) p. 766 May 1, 2001 ASAP, Cliggott Publishing
Co.
Each year, an estimated 98,000 Americans die because of medical errors.
Up to 4% of inpatients experience some type of medication error. Common
ones involve sound-alike drug names (nevirapine, nelfinavir). Dose calculation
errors can occur if the basis should be ideal body weight (as for digoxin)
rather than actual body weight. Prescribing the wrong dosage form can
lead to significant discrepancies in therapeutic effect. Writing the
wrong frequency (tid instead of q8h) can skew trough and peak blood levels.
Failure to adjust doses for renal dysfunction is especially common. Strategies
being developed to prevent these and other errors such as decimal point
misplacement, abbreviation use, overlooked drug interactions, and incomplete
patient history--include physician order entry, consulting a clinical pharmacist,
improving medication education, and handheld electronic personal data
assistants.
In recent years, public attention has focused on a problem that
has long plagued the medical community: medication errors. Studies
have tallied the cost of these errors in needless deaths, morbidity, and
health care expenses. [1] The US Institute of Medicine estimates that
each year up to 98,000 Americans die because of medical errors. [2]
Thus, medical errors cause more deaths than motor-vehicle accidents, AIDS,
breast cancer, or work place accidents. [2] These errors encompass
all medical activities; however, medication-related errors are the
largest category.
1. Sound-alike Drugs;
2. Lack of Drug Knowledge;
3. Dose Calculation Errors;
4. Decimal Point Misplacement;
5.Wrong Dosage Form;
6. Wrong Frequency;
7. Use of Abbreviations;
8. Drug Interactions;
9.Renal Insufficiency;
10. Incomplete Patient History
TOP Citations to IOM report
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.
Since its release nearly three years ago, the Institute of Medicine's startling report on medical errors has triggered a frantic national effort to do something--anything--about patient safety.
It also has touched off a related and equally frenetic flurry of activity across America: a blizzard of ''patient-safety awards'' now being bestowed by hospitals, healthcare organizations and government agencies to help publicize and promote efforts to reduce medical errors and accidental deaths.
Proponents say this recent spate of awards--the industry's ever-expanding version of the Oscars--is a way to recognize legitimate patient-safety efforts and foster continued improvement. But some consumer advocates have criticized this trend, denouncing the wave of awards as little more than self-serving marketing efforts that detract attention from a critical challenge.
''I think it's window dressing,'' says Arthur Levin, director of
the New York-based Center for Medical Consumers, a not-for-profit patient-advocacy
group. ''My gut feeling tells me that there's been little real progress
in patient safety (since the IOM report). All these awards are a way for a
large organization to say, 'We're on board this safety movement.' This
is easy and cheap, and it makes everybody look concerned. The awards
are nice, but is this really dealing with this enormous problem effectively?
The answer is no.''
TOP Citations to IOM report
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) .
Reporting medical errors and adverse events;
Research Corner.
AORN Journal April 1, 2002 ; JCAHO call for Safety
Unlike the aviation industry, the health care industry does not have a structured, systematic approach for reporting errors and adverse events. Learning from errors is a key component of safety initiatives in both military and civilian aviation. Accidents, near misses, and occurrences that actually affect or could affect safe operations of an aircraft are reported to the National Aeronautics and Space Administration's (NASA's) Aviation Safety Reporting System (ASRS) and studied extensively. Knowledge derived from secondary analyses and interview data obtained regarding various incidents results in the dissemination of safety alerts and monthly safety bulletins.
SAFETY IN AVIATION
Overall safety in the airline industry is protected by three organizations: the Federal Aviation Administration (FAA), the National Transportation Safety Board (NTSB), and the ASRS. The FAA maintains regulatory oversight of the industry and focuses primarily on safety. The NTSB investigates accidents, and, although it has no regulatory or enforcement authority, it can make recommendations to the FAA. The ASRS operates independent of the FAA and has no regulatory or enforcement powers related to civilian aviation.
VA tries to learn from its mistakes; Hospitals
focusing on errors, not blame, to revolutionize care
The Baltimore Sun December 22, 2001;
VA tries to learn from its mistakes; Hospitals focusing on errors, not blame, to revolutionize care
James Leon Thompson, a 53-year-old Army veteran with an infected leg, sprawls in a bed at the Baltimore VA Medical Center, his wrist wrapped in a bracelet bearing a bar code like the kind found in supermarkets.
A nurse, Shelly Epps, unholsters a gun from her cart and shoots a needle-thin ray of red light across his bracelet. She then flicks the laser across the bar code on a package of blood pressure pills.
An error message flashes on a computer mounted on her cart: "Scanned Drug Not Found on Viable Drug List." Corrected by the machine, she pulls out a bag of antibiotics, which the computer tells her is the right drug for Thompson.
PR Newswire
January 17, 2002, Thursday
Hospital Patient Safety Information Gives Consumers the Power To Make
More Informed Health Care Choices;
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
Making informed hospital choices just got easier. The Leapfrog
Group, founded by the Business Roundtable, has unveiled the initial results
of a voluntary and ongoing patient safety survey among urban hospitals in
six U.S. regions. Forty-eight percent (48%) of invited hospitals (241 out
of 497) completed a survey on three pioneering practices proven to reduce
preventable medical mistakes. In both East Tennessee and Seattle-Tacoma-Everett,
92 percent of invited hospitals responded to the survey. Fifty-three percent
(53%) of hospitals submitting responses meet at least one of the Leapfrog
standards for these safety practices.
The survey asked urban hospitals whether they have implemented or plan to
implement computerized physician order entry (CPOE) and staffing of the Intensive
Care Unit (ICU) with trained specialists (intensivists). For the third practice,
evidence-based hospital referral, the survey queried hospitals about how many
times a year they perform five high-risk surgeries and asked those with neonatal
ICUs (NICU) about how many infants they typically care for each day. Survey
information is available to consumers online at http://www.leapfroggroup.org
.
"Thoughtful corporations provide information that helps employees make intelligent
and informed health care decisions," said Charles R. Lee, chairman and co-CEO
of Verizon Communications. "The Leapfrog Group initiative helps Verizon
empower more than 1 million employees, retirees, and members of their families
by putting usable health care information in their hands.
Together with the entire health care industry, we believe we can encourage
continuous improvement in patient safety."
http://www.leapfroggroup.org
TOP Citations to IOM report
In search of safety: an interview with Gina
Pugliese;
Nursing Economics January 1, 2002 http://www.premierinc.com/
* Gina Pugliese, MS, RN, is currently a vice-president for Premier,
Inc. In addition to faculty and editorial positions, she directs international
training courses in hospital epidemiology. She has made innumerable
contributions to the field of safety over the past 25 years through her
work with regulatory and federal agencies.
* Changing organizational culture from a "blame culture" to a "safety
culture" is one notable challenge facing organizations.
* The airline industry has achieved significant changes in its safety
culture by virtually eliminating a power hierarchy in the cockpit, a
worthy example for operating rooms.
* Redesigning care delivery processes will minimize the opportunity
for error if efforts are made to avoid reliance on memory, automate
repetitive functions, reduce the number of steps involved, or use protocols
when appropriate.
TOP Citations to IOM report
Building an Electronic Network of Care; Group Seeks to Cut Medical Errors by Sharing InformationWhile Guarding Privacy Washington Post, December 12, 2001
An initiative announced yesterday may soon give patients the option of making key information from their medical records available electronically to all of the doctors, hospitals and pharmacies involved in their care.
Fragmentation and lack of communication among caregivers are widely cited by critics of the U.S. health care system as a major source of medical errors, unnecessary spending and inadequate care.
The project by the Patient Safety Institute (PSI), a new nonprofit organization, will seek to address those problems by creating an electronic network that would allow participating doctors and health care institutions to share information that is often needed to make medical decisions -- such as the list of a patient's current medicines, recent laboratory tests, allergies and immunization record.
"Privacy is paramount. The consumer should not have to give
up any privacy whatever if this is done properly,"
said Dee Hock, an adviser to PSI and the founder of Visa International,
an international financial network that
allows banks in more than 200 countries to share information
for credit card transactions.
TOP Citations to IOM report
State awarded $ 4.5m to fight medical errors
The Boston Herald October 30, 2001; NEWS; Pg. 016
The state Department of Public Health has been awarded a $ 4.5 million federal grant to evaluate and improve the state's existing system for reporting medical errors.
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.
"This allows us to put some dedicated dollars specifically into
patient safety," said Nancy Ridley, assistant commissioner of public
health for health care quality, who will oversee the effort.
TOP Citations to IOM report
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
Paths to reducing medical injury: professional liability and discipline vs. patient safety -- and the need for a third way.
Too many patients are injured in the course of care. Clinicians may mistakenly cause new harm to a patient or fail to take established steps to improve the presenting condition. Medical institutions within which they work may lack mechanisms to reduce errors or prevent them from harming patients. Many, perhaps even most, injuries are preventable, probably numbering in the hundreds of thousands a year for hospital care alone. Long ignored by medical practitioners and health-care payers and little appreciated by the public, the problem of medical injury is finally receiving high-level policy attention. Much credit goes to the Institute of Medicine (IOM) for its landmark report of November 1999, which marshaled the evidence about medical injuries and highlighted new approaches to systematic improvement of safety within systems of care. (1)
Two competing worldviews seek to define the problem and channel
the policy response. One is the traditional perspective that practitioners
are in charge, need to be held personally responsible, and should take the
primary blame for injuries. Call this the "professional sanctions" view. Interestingly,
physicians and attorneys tend to share this perspective, which emphasizes
penalties for transgressions, although doctors and lawyers hold very
different views about the sanctions to be applied -- medical peer review
vs. professional liability lawsuits.
TOP Citations to IOM report
To err is human: How to prevent medical errors.
Patient Care June 15, 2001; Pg. 95
A recent 10M report raised awareness of the seriousness and extent
of hospital-based errors. But mistakes occur in office practices, as well.
Our experts give advice on how to avoid medical missteps.
The pharmacist called this morning with a query about one of the prescriptions
that you wrote. He thought a decimal point was in the wrong place, and he
was right. How often have similar mistakes gone unnoticed? Since the Institute
of Medicine (IOM) report on medical errors was published, the media have been
focusing on hospital-based mistakes because those were the subject of the
report. [1] But mistakes occur in the primary care office on a daily basis,
and some of them are never discovered. Does a remedy exist?
The medical-errors arena is undergoing a transformation. Experts
now recommend looking not at individuals, but at systems and processes as
the critical sources of most mistakes. The focus has shifted to designing
office procedures so mistakes are caught before they affect patients. Because
problems cannot be solved until they are identified, staffers must be enabled
to move away from a punitive culture that assigns blame for mistakes. Individual
employees must be relatively free to report errors--and near misses--without
fear of reprisal. Some institutions go so far as to send thank-you letters
to employees who report mistakes.
http://www.usp.org/reporting/review/qr66.pdf.1000
name pairs that have been confused on prescriptions have been identified
http://www.fda.gov/cder/cdernew/
listserv.html and MedWatch at
http://www.fda.gov/medwatch
http://www.fda.gov/cder/cdernew/listserv.html
TOP Citations to IOM report