Case Study Chemotherapyrelated medication errors

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Patients Safety Could It Truly Be This Awful?
Marwan GHOSN,MD, MBA/MHM
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Objectives

• Sensitize the audience on the dimension of the
  problem
• Define the medication error and its impact on
  Patient Safety and Healthcare System
• Emphasize on the role of nurses on Patient Safety
• Quality and Patient Safety
• Hospital Accreditation

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Six Key Aims of Health CareSafety Comes First !

• Safe avoid injuries to patients
• Effective based on science
• Patient centered respectful, responsive
• Timely reduces wasteful delays
• Efficient avoid waits
• Equitable across gender, race, location,
• and ability to pay

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Medication Errorsin numbers
26 December 2009
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When Mistakes are not an Option
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gt 1,000,000 Serious Medication Errors per year
in USA...
Ref Wall Street Journal/Institute of Medicine
26 December 2009
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When Mistakes are not an Option
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195,000 hospital deaths per year in the U.S.as
a result of healthcare error2000-2002
Source Boston Globe 27.July.2004 HealthGrades
/ Denver
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44,000 preventable deathsoccur each year
Source Boston Globe 27.July.2004 HealthGrades
/ Denver
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When I climb Mount Rainier I face less risk of
death than I face on the operating table.
Donald Berwick, Six Keys to Safer Hospitals A
Set of Simple Precautions Could Prevent 100,000
Needless Deaths Every Year, Newsweek
(12.12.2005) Donald Berwick is the President
CEO of the Institute of Healthcare Improvement
(IHI)
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Tommy Thompson, Secretary of the United States
Department of Health human Services
(2001-2005)"Some grocery stores have better
technology than our hospitals and clinics.
Source Special Report on technology in
healthcare, U.S. News World Report (07.04)
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Do these numbers give you a pause when you
will decide to go to the hospital ?
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What is Medical Error?
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Definition of a Medication Error

• Any preventable event that may cause or lead to
  inappropriate medication use or patient harm
  while the medication is in the control of the
  health care professional, patient, or consumer.

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Medication Error include

• Delayed diagnoses
• Mistakes during treatment
• Medication mistakes
• Delayed reporting of results
• Miscommunications during transfers and
  transitions in care
• Inadequate post-procedure care
• Mistaken identity

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Medication Error include

• Error of commission
• Act of doing something incorrectly
• Under normal circumstances that dont include
  stress time pressures 3 times out of 1000
• Errors of omission
• Something that should be done are not done
• In the absence of reminders 1 time in 100

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Examples

• Transdermal patches
• Appliance of the new patch directly on top of the
  old one.
• Not removal of the protective linear
• Not removal of the old patch when the new patch
  is applied.
• Difficult to find clear patches on the skin
• Accidental and intentional ingestion

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Medication Error-prevention Strategies

• Educational and competency requirements for
  practitioners
• Organized and up-to-date patient medical record
  and medication profile
• Coordinated care among practitioners.
• Standardized medication ordering system
• Preprinted medication order forms
• Computerized prescriber order entry system
• Standardized format for medical order content
  including dosage calculations, vocabulary and
  nomenclature, abbreviations, dosage limits and
  routes of administration.

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Medication Error-prevention Strategies

• Standardized protocols for prescribing,
  preparation, dispensing, and administration of
  medication
• Medication-order verification system (9
  checkpoint system)
• Documentation such as checklists, worksheets to
  calculate dosages and administration rates, and
  treatment flow sheets
• Cross-checking
• Manual or electronic medication monitoring
• Patient and caregiver education

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Medication Error-prevention Strategies

• Quality assurance
• Periodic auditing of practitioner proficiency
• Error reporting system
• Analysis and resolution of medication errors
• Periodic re-evaluation of medication use system

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What are the impacts of medical error?

• Harm to the patient
• Moral Imperative
• Professional Imperative
• Financial Imperative

Lets have a look on some concrete numbers
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Medical errors result in injury cost 17 to 29
Billion each year in USA
Ref Kohn LT, Corrigan JM, Donaldson MS (eds).
Committee on Quality of Health Care in America,
Institute of Medicine. To Err is Human Building
a Safer health System. Washington, DC National
Academies Press 1999.
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Nosocomial bloodstream infections prolong a
patients hospitalization by a mean of 7 days
gtCost per bloodstream infection range 3,700
and 29,000
Ref Soufir L, Timsit JF, Mahe C, Carlet J,
Regnier B, Chevret S. Attributable morbidity and
mortality of catheter-related septicemia in
critically ill patients A matched,
risk-adjusted, cohort study. Infection Control
and Hospital Epidemiology. 1999 20 (6) 396
401.
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Preventable Adverse drug events increase in
length stay of 4.6 days at a cost of 4,685 each
Ref Soufir L, Timsit JF, Mahe C, Carlet J,
Regnier B, Chevret S. Attributable morbidity and
mortality of catheter-related septicemia in
critically ill patients A matched,
risk-adjusted, cohort study. Infection Control
and Hospital Epidemiology. 1999 20 (6) 396
401.
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Focusing On Nursing !
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Nurse Staffing, Quality of Care Outcomes
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Educational levels of hospital nurses and
surgical patient mortality
JAMA 2003
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Nurse Staffing and impact on clinical outcome
Ref Aiken LH, Clarke SP, Sloane DM, Sochalski J,
Silber JH. Hospital nurse staffing and patient
mortality, nurse burnout, and job
dissatisfaction. JAMA. 20022881987-1993. Aiken
LH, Clarke SP, Cheung RB, Sloane DM, Silber JH.
Educational levels of hospital nurses and
surgical patient mortality. JAMA.
20032901617-1623. Aiken LH, Clarke SP, Sloane
DM, for the International Hospital Outcomes
Research Consortium. Hospital staffing,
organization, and quality of care cross-national
findings. Int J for Qual Health Care.
2002145-13.
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Education and work environment impact on clinical
outcome

• Every 10 increase in the proportion of a
  hospitals staff nurse workforce with a
  baccalaureate degree or even higher levels of
  education is associated with a 5 decline in
  mortality.
• Hospitals with better nurse work environments
  have fewer adverse patient outcomes than
  hospitals with poorer work environments.

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Turnover rateExperience of Hackensack
Hospitalin New Jersey

• Relates its low voluntary turnover rate of RN
  (6.3) to the excellent practice environment for
  nurses.
• This translates into savings of 45,000 to
  68,000 in recruitment training expenses for
  each nurse.
• A low turnover rate is associated with a culture
  that supports patient safety
• The nursing practice environment is critical to
  patient safety, quality of care nurse retention.

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Significant progresses have been made when
looking at local results under surveillance
Micro Results Significant Progress
Leape Berwick, JAMA 2005
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But much little progresses when looking at macro
results
Macro Results Little Progress
Global shift safety improvement along time of
all human activities (order of magnitude one
log every 20 years) but the relative ranking of
activities does not seem to change
Fatal Iatrogenic adverse events
Anesthesiology ASA1
Cardiac Surgery Patient ASA 3-5
Medical risk (total)
No system beyond this point
Hymalaya mountaineering
Chartered Flight
Civil Aviation
Railways (France)
Microlight or helicopters spreading activity
Road Safety
Nuclear Industry
Chemical Industry (total)
Fatal risk
10-2
10-3
10-4
10-5
10-6
Very unsafe
Ultra safe
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Conclusion (1)

• The environments in which nurses work are complex
  systems that are prone to error.
• Errors in nursing care are rarely due to
  carelessness or incompetence.
• Consequently, the culture of health care
  organizations, created in part by nurses, needs
  to be blame free.
• A learning environment, with free flowing open
  communication enables nurses to identify, discuss
  and ultimately prevent health care errors.

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Conclusion (2)

• Patients deserve and have a right to care that
  minimizes the likelihood of errors and that puts
  their safety first.
• To achieve that aim, nurses and other
  stakeholders in health care have significant work
  ahead.

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Safety Begins with you
Dont Wait for someone else