Consequences Of Medication Errors Research Articles

Patients disclosure in health plan: Quality of care and physician competence

Medical error and tort reform have increasingly taken center stage in the health care debate in our region and all over the world. Patients, policy makers and health care professionals grapple with the striking prevalence and consequences of medical error, may result in patient injury from the health care providers. Fears of malpractice liability, difficulties in communicating with patients and their families, inattention to their problems in details and giving inadequate time to them in listening and discussion, in addition to confusion about causation and responsibility, all have long impeded comprehensive and bold initiatives designed to change the patient, family and clinician experience with medical error. Offering an apology with complete patient respect and transparency with full disclosure of harmful medical errors to the patients and their families can do much to defuse the hurt and anger that can lead to further emotional and physical trauma. Health care professionals including doctors need to communicate with patients or their parties in their day to day activities. It should be an essential habit of doctors. In the present medical curriculum in medical education, emphasis was placed on learning communication skills by the undergraduate doctors. Key words: Kingdom of Saudi Arabia (KSA), discourse completion test (DCT), patients,health care.

Impact of apology on health care system; communication skills

Medical error and tort reform have increasingly taken center stage in the health care debate in our region and all over the world. Patients, policy makers and health professionals grapple with the striking prevalence and consequences of medical error, which result in patient injury and health care service. Debate ranges from legislating restrictions on cost awards in malpractice trials to ethical and moral imperatives germane to untoward clinical incidents, whether in the hospital or in outpatient settings. Fears of malpractice liability, difficulties in communicating bad news, and confusion about causation and responsibility, have long impeded comprehensive and bold initiatives designed to change the patient, family and clinician experience with medical error. Offering an apology and making full disclosure of harmful medical errors to patients and their families can do much to defuse the hurt and anger that can lead to further emotional and physical trauma.

Medical error and harm: understanding, prevention, and control

Putting medical error and harm in context. Reducing errors and harm in medicine beyond the 'oops!' factor Errors as part of advances in medicine How can we look at and consider medical errors today What is covered in this book The view of medical error problem in the light of the recent experience Medical error and patient safety How this book might contribute to the present state of human error experience and patient safety The valued legacy. Error and harm across general human experience in the non-medical domains. Welcome to lathology. A brief history of the recent human error experience Definition of human error and other related terms Taxonomy of error Cognition and cognitive process at the core of error, and of its understanding and control Models of error, their development and contributing sites and entities in context An epidemiological approach to the error problem human error domain through the eyes of medicine and epidemiology Implications regarding the search for understanding, control and prevention of error today Ensuing state of the human error domain today Error and harm in the health sciences. Defining and classifying human error and its consequences in clinical and community settings Overview of our today understanding of error today Overview of approaches to error in medicine Definition of medical error Variables and their taxonomy in the medical error domain Describing medical error and harm. Their occurrence and nature in clinical and community settings Research, knowledge acquisition, and intervention strategies in the general error domain as viewed by a methodologically minded physician-epidemiologist Descriptions of single cases, small sets of error cases and harm cases Back to epidemiology: what happens now? Occurrence studies, descriptive epidemiology, magnitude and distribution ('in'whom, where and when') of the error and harm problem How to describe and report the occurrence of medical error and harm very brief guidelines Analyzing medical error and harm. Search for their causes and consequences Searching for new (yet unknown) causes and consequences of medical error and harm etiological research, analytical observational epidemiology Challenge of deriving cause-effect relationships from one or very few past observations a priori causal attribution Off beat searches for causes siding with mainstream epidemiological experience Experimental demonstration of medical error and harem causes and its compromises and alternatives Is the mainstream epidemiological methodology of causal research feasible in the domain of medical error and harm? Flaws in operator's reasoning and decision making before action Note about medical error and medical harm System error vs. individual human error Reminder regarding some fundamental considerations Flawed argumentation and reasoning as sites and generators of error and harm argumentation and human error and harm analysis from a logical perspective Where and when errors occur. Cognitive pathways as sites of error Prevention, intervention and control of medical error and harm. Clinical epidemiological considerations of actions and their evaluation Basic definitions, concepts and strategies of intervention in lathology Basic angles of evaluation in lathology: Structure, process, outcomes, and other subjects to evaluate What should be evaluated at the individual level: knowledge, attitudes, and skills Experimental, quasi-experimental and non-experimental evaluation of interventions to understand and better control medical error and harm problems Taking medical error and harm to court. Contributions of physicians and expectations of physicians in tort litigation and legal decision-making Medical, surgical and public health malpractice claims and litigation Language of medicine and law General philosophy and strategies of medicine and law The law process and its stages Cause-effect relationships in medicine and law Litigating the argumentative way Disclosure of medical errors: Working in law and epidemiology with what is available A difficult mix: medicine, ethics and law Conclusions Challenges in focus Confounding error and harm Persisting diversity of semantics and taxonomy Lack of epidemiology Dichotomy in lathology Lack of training in lathology Better knowledge, attitudes and skills in the management of error and harm A need for better knowledge of cases of error and harm Challenge of communication Interaction between stakeholders in the error and harm domain in medicine Psychological, social and legal challenges to perpetrators of error and creators of harm Material gains and losses related to error and harm Possible ethical challenges Individual human error vs. system error Lack of pragmatic choices regarding what to do in lathology Unexpected roles, uses and potentials of logic, critical thinking and evidence in generating error management activities Legal considerations A Brief and (hopefully) Harmonized Glossary Appendices

Medication errors management process in hospital: a 6-month pilot study

The objectives of this study are to assess the relevance of the medication error reporting system in a French teaching hospital, to enable the collection of medication error reports and to take corrective actions to reduce occurrence. This is a prospective pilot study based on blame-free reporting by healthcare professionals. The study setting is five medical/surgical departments in a French teaching hospital over a 6-month period. The main outcomes of this study are types, frequency, and consequences of medication errors reported. Over a 6-month period, 47 medication errors were reported. Twenty-eight (60%) were related to the prescription process, of which 17 were prescribing errors, 10 were because of data capture error and one was because of software malfunction. Ten medication errors (21%) were related to the dispensing process and eight (17%) to errors occurring during drug administration. Finally, one medication error (2%) was related to prescription, dispensing, and administration. The reporting process was accepted by most healthcare professionals who agreed to initiate medication errors reports upon assurance that data collection will be confidential. The reporting process led to several avoidance actions to minimize the medication error risk. Maintaining confidentiality embedded within a nonpunitive environment, this method was accepted by all participating personnel. Medication errors could be collected, reviewed, and corrective actions taken. This strategy can be a first step in a long-term ongoing process to prevent future medication errors in hospitals.

Nursing, System Design, and Health Care Quality

OCTOBER 2009, VOL 90, NO 4 • AORN JOURNAL • 581 he consequences of medical errors and poor health care quality affect our lives directly and indirectly. Most physicians, nurses, and other health care workers have had firsthand experiences with near errors, adverse events, or care of such poor quality that it should never have been delivered to a patient. Adverse events, in particular, can be traumatic for the caregiver as well as for the patient and his or her family. Unfortunately, when errors occur or the quality of care is poor, a natural instinct is to look for someone to blame. Oftentimes, the blame falls to a nurse, despite the fact that system design factors, not human factors, actually comprise the majority of errors and poor quality care. System design factors are often to blame for errors and poor quality in the OR. Unfortunately for those who work in the OR, this setting is often less visible than other care settings. To many observers, the OR remains a place of mystery—even to those who work in other health care settings. The doors are closed, the patient is anesthetized, and there are no visitors. No one is watching. If the perioperative nurse does not speak up on behalf of the patient, it is quite possible that nobody will. This places tremendous responsibility and stress on perioperative nurses. Nurses protect patients in so many ways. In the OR, this responsibility can include maintaining the sterile field to guard against infection, speaking up during a procedure to prevent an error, and assessing and managing pain. These are duties of enormous importance that ultimately place nurses at the “sharp end” of patient care; thus, they bear the responsibility to intercept an error. This position is untenable unless systems are put in place to lessen the likelihood that human error—which is inevitable—will turn into medical error, which is not. System design factors present the potential for many errors; therefore, we must work diligently to improve system design. To prevent adverse events and ensure higher quality care, the systems in which we work need to be adapted to reflect our human strengths and weaknesses. They also should be designed to ameliorate the effects of whatever human error occurs.

Drug effectiveness reporting and monitoring systems: discussion and prototype development

While tracking systems have been developed to decrease occurrences and consequences of medication errors in healthcare facilities, there is a growing need for similar systems to monitor drugs that have just entered the market with unknown adverse events. Between 1997 and 2005, the FDA's MedWatch system successfully identified 15 drugs with toxic side-effects; it took an average of 5.9 years for identification and removal of such drugs. We propose an online surveying system, coupled with continuous monitoring by participating pharmacists, that could significantly reduce the identification time and the removal time. Further, we analyse the potential for leveraging advances in semantic web and ontology development to populate the database of the proposed system.

Automation, Decision Support, and Expert Systems in Nephrology

Increasing data suggest that errors in medicine occur frequently and result in substantial harm to the patient. The Institute of Medicine report described the magnitude of the problem, and public interest in this issue, which was already large, has grown. The traditional approach in medicine has been to identify the persons making the errors and recommend corrective strategies. However, it has become increasingly clear that it is more productive to focus on the systems and processes through which care is provided. If these systems are set up in ways that would both make errors less likely and identify those that do occur and, at the same time, improve efficiency, then safety and productivity would be substantially improved. Clinical decision support systems (CDSSs) are active knowledge systems that use 2 or more items of patient data to generate case specific recommendations. CDSSs are typically designed to integrate a medical knowledge base, patient data, and an inference engine to generate case specific advice. This article describes how automation, templating, and CDSS improve efficiency, patient care, and safety by reducing the frequency and consequences of medical errors in nephrology. We discuss practical applications of these in 3 settings: a computerized anemia-management program (CAMP, Henry Ford Health System, Detroit, MI), vascular access surveillance systems, and monthly capitation notes in the hemodialysis unit.

Medication errors among acutely ill and injured children treated in rural emergency departments.

We identify the incidence, nature, and consequences of medication errors among acutely ill and injured children receiving care in a sample of rural emergency departments (EDs). Two pediatric pharmacists applied a medication error data collection instrument to the medical records of all critically ill children (highest triage category) treated in 4 northern California rural EDs between January 2000 and June 2003. Physician-related medication errors were defined as those involving wrong dose, wrong or inappropriate medication for condition, wrong route, or wrong dosage form. Wrong dose was determined by preset criteria, with doses above or below 10% to 25% of correct dose considered errors, depending on class of medication. Medication errors were classified into categories A through I under 3 broader categories, including errors having the potential to cause harm (A), errors that cause no harm (B to D), and errors that cause harm to the patient (E to I). Complete data were available from 177 (97.3%) of the 182 patients identified as having been triaged in the highest category during the study period. A total of 84 medication errors were identified among 69 patients, resulting in a medication error incidence of 39.0%. Twenty-four physician-related medication errors were identified among 21 patients, resulting in a physician-related medication error incidence of 11.9%. Among the 69 patients with medication errors, 11 had errors categorized as having the potential to cause harm (15.9%), and 58 had errors categorized as causing no harm (85.5%). We found a high incidence of medication errors and physician-related medication errors among the acutely ill and injured children presenting to rural EDs in northern California. None of the medication errors identified caused harm to the patients included in this study.

Simulators in Interventional Radiology Training and Evaluation: A Paradigm Shift Is on the Horizon

A paradigm shift at the turn of the 20th century changed the face of graduate medical education with the birth of the concept of residency. A century later, medical education requires another paradigm change, this time triggered in part by concerns over patient safety. Publication of the Institute of Medicine (IoM) report “To Err is Human: Building a Safer Healthcare System” in 1999 (1) highlighted for the first time to the public, medical professionals, and the government the realities and consequences of medical errors.

The Perruche case and the issue of compensation for the consequences of medical error

The case of Nicolas Perruche gave rise to a national debate in France over compensation for serious consequences of medical error. Ultimately, legislation was enacted banning the cause of action known in Anglo-American law as wrongful life, and an agency was established to adjudicate subsequent claims. As other developed nations continue to wrestle with rapid increases in the cost of professional liability coverage and health care in general, a review of the Perruche case and its influence on French health policy may advance the discussion beyond the current stalemate of hardened advocacy positions.

Inappropriate Drug Combinations Among Privately Insured Patients With HIV Disease

The objective of this study was to examine inappropriate drug combinations among privately insured patients with HIV disease. Data were obtained from the MarketScan Commercial Claims and Encounter Database for the years 1999 and 2000. Each of the 2110 person-years of data examined in this study represents the claims experience of an enrollee with HIV disease who filled an antiretroviral medication prescription in either 1999 or 2000 for a protease inhibitor or nonnucleoside reverse transcription inhibitor. This study compares the claims experience of patients with HIV who filled a prescription for an inappropriate drug combination as specified in guidelines jointly issued by the U.S. Department of Health and Human Services and the Henry J. Kaiser Family Foundation with the claims experience of patients who did not. An inappropriate drug combination was found in approximately 2% of the person-years of data, and persons who experienced an inappropriate drug combination had higher claims costs. One half of all of the inappropriate drug combinations involved a single lipid-lowering agent (simvastatin). Protease inhibitors decrease the activity of the enzyme that metabolizes simvastatin, and high concentrations of simvastatin have been associated with muscle damage. We found that patients who received protease inhibitors and simvastatin were more likely to experience muscle damage. Persons with HIV have compromised immune systems and often take many medications. Thus, the risk and consequences of medication errors are severe, and both providers and patients should carefully monitor drug regimens to ensure that they are both safe and efficacious.

Errors in the medication process: frequency, type, and potential clinical consequences

To investigate the frequency, type, and consequences of medication errors in more stages of the medication process, including discharge summaries. A cross-sectional study using three methods to detect errors in the medication process: direct observations, unannounced control visits, and chart reviews. With the exception of errors in discharge summaries all potential medication error consequences were evaluated by physicians and pharmacists. A randomly selected medical and surgical department at Aarhus University Hospital, Denmark. Eligible in-hospital patients aged 18 or over (n = 64), physicians prescribing drugs and nurses dispensing and administering drugs. Frequency, type, and potential clinical consequences of all detected errors compared with the total number of opportunities for error. We detected a total of 1065 errors in 2467 opportunities for errors (43%). In worst case scenario 20-30% of all evaluated medication errors were assessed as potential adverse drug events. In each stage the frequency of medication errors were-ordering: 167/433 (39%), transcription: 310/558 (56%), dispensing: 22/538 (4%), administration: 166/412 (41%), and finally discharge summaries: 401/526 (76%). The most common types of error throughout the medication process were: lack of drug form, unordered drug, omission of drug/dose, and lack of identity control. There is a need for quality improvement, as almost 50% of all errors in doses and prescriptions in the medication process were caused by missing actions. We assume that the number of errors could be reduced by simple changes of existing procedures or by implementing automated technologies in the medication process.

68 Medication Errors in A Neonatal Unit

Background: The magnitude and consequences of medical errors are controversial issues; nevertheless, there is a consensus on the preventability of medication errors and their frequent occurrence. Aim: To determine the frequency of different types of error in medical prescriptions and to estimate its occurrence as a function of characteristics and circumstances of the prescriptions. Methods: Cross-sectional study of hand-written prescriptions for newborn infants admitted to a third level neonatal unit during a 5 months study period (july–november 2003). Data were extracted from all prescriptions written on 53 randomly sampled days. Outcome variables: different elements were assessed to describe the correction of a prescription (drug name, dose, units, administration route, interval, legibility); a prescription was considered correct when all its elements were present. Determinants: characteristics and circumstances of the prescriptions (type of drug, day of the week, night/day shift, training of the prescriber and clinical profile of the patient). Data analysis: Proportions and logistic regression adjusted odds ratio (95% confidence interval). Results: 4132 hand-written prescriptions were reviewed. 58.6% of the prescriptions fullfilled the correction criteria. 88% of incorrect prescriptions were intercepted. No adverse effect was related to a prescription error. Dose calculation was incorrect in 12.3% of the prescriptions. An incorrect abbreviation of the units was used in 8.4%; 4% did not stated dose interval and 2.8% stated an incorrect interval. At least one of the elements of the prescription was considered illegible or uncertain in 13.7%. The route of administration was not stated in 12.7%, and it was not correct in 0.7%. The drugs with the higher proportion of incorrect prescriptions were caffeine and erythropoietin. Prescriptions were more frequently correct for newborns admitted to intensive vs. intermediate care, 1.5 (1.3–1.7); birth weight over 2500 g, 1.9 (1.5–2.4); on week-ends vs. rest of the week, 1.3 (1.1–1.5); on afternoon/night vs. morning shifts, 1.8 (1.4–2.3); and when written by intraining vs. staff doctors, 1.5 (1.4–1.8). Conclusion: More than half of prescriptions written out by hand in a neonatal unit were not considered correct. A higher workload is not related with a higher number of incorrect prescriptions. Professional experience does not reduce, in general, the number of prescription errors. The occurrence of miscalculation of dose was higher for medication prescribed daily or routinely.

What do we know about medication errors in inpatient psychiatry?

Adverse drug events (ADEs) have been implicated as a cause of substantial morbidity and mortality. Psychiatrists have successfully characterized one category of ADE--adverse drug reactions (ADRs), which have been studied from a medication-specific psychopharmacology frame of reference. The literature on ADEs, both preventable and nonpreventable, was reviewed within the broader patient safety framework. English-language studies involving ADEs and medication errors in psychiatry for 1996 through 2003 were identified on MEDLINE and by using a hand search of bibliographies. Few reports on the incidence and characteristics of medication errors in psychiatric hospitals could be found. Psychiatrists may not be sufficiently aware of the harm caused by errors, methodological issues regarding error detection, the validity of reported medication error rates, and the challenge of creating a nonpunitive error-reporting culture. PREVENTION STRATEGIES: Application of a systems-oriented approach to ADE reduction and the promotion of a nonpunitive culture are essential. Clinical and pharmacy staff could monitor the literature for published reports of preventable adverse events and review those reports in multidisciplinary team meetings. Psychiatry would benefit from learning about the terminology used in describing medication errors and ADEs. Relatively few data are available regarding the frequency and consequences of medication errors in psychiatry; more research is needed.

Exploring the issues of appropriate dosing in the treatment of acute myocardial infarction: Potential benefits of bolus fibrinolytic agents

The Institute of Medicine report on the frequency and consequences of medical errors in clinical practice has stimulated physicians to evaluate current practice and means of improving medical care. In the treatment of patients with acute myocardial infarction, previous studies have found that dosing of fibrinolytic therapy is closely related to outcomes, with too low a dose associated with lower rates of infarct-related artery patency and higher doses associated with increased intracranial hemorrhage. Thus there is a narrow ″therapeutic window” for fibrinolytic-antithrombotic regimens, and the potential for adverse outcomes is high if incorrect doses are administered. The first demonstration of this concept came from the GUSTO-I trial, in which 13.5% of patients treated with streptokinase and 11.5% of patients treated with tissue plasminogen activator (t-PA) had a dosing regimen that deviated from the protocol, that is, an incorrect total dose or infusion length. In patients with protocol deviations, 24-hour and 30-day mortality rates were significantly higher compared with those of patients with per-protocol dosing: for t-PA, patients who received incorrect dosing had a 30-day mortality rate of 7.7% versus 5.5% for patients who received correct t-PA dosing (P < .001), with similar findings for streptokinase. More recent data from the InTIME-II trial have shown that the use of a bolus fibrinolytic agent significantly increases the percentage of patients who receive complete and optimally dosed fibrinolysis. Thus use of the simpler bolus fibrinolytic agents may reduce medication errors and thus may optimize clinical outcomes. (Am Heart J 2000;140:S154-60.)

Medication errors in paediatric practice: insights from a continuous quality improvement approach.

The objective was to assess the incidence and consequences of medication errors, highlight sources of recurrent error and institute changes in practice to prevent their recurrence. Utilising a continuous quality improvement approach, a 2-year prospective cohort study was undertaken using an adverse incident reporting scheme. A multidisciplinary committee analysed medication error reports, classifying them according to type (prescription, supply or administration), severity (serious or not serious) and clinical outcome. Changes in policy and practice were implemented to reduce the frequency of errors. There were 441 reported medication errors in the study period, during which 682 patients were admitted for 5315 inpatient days. Errors were more seven times likely to occur in the intensive care setting. Doctors accounted for 72% of errors and prescription errors doubled when new doctors joined the rotation. Most errors (68%) were detected prior to drug administration. Twenty-four serious medication errors were not detected in advance, but only 4 had overt clinical consequences. Excluding prevented errors and appropriate deviations from prescribed therapy, there were 117 actual medication errors (1/5.8 admissions, or 1/45 inpatient days). During the 2nd year of the scheme, the incidence of all reported errors, administration errors and serious errors fell, but the prescription error rate remained constant. Medication errors occurred commonly in this study, but adverse consequences were rare. The non-punitive, multidisciplinary approach to medication errors utilised in this study increased staff vigilance, highlighted sources of recurrent error, and led to changes in drug policies and staff training, which resulted in improved patient safety and quality of care.