Clinical errors - their causes and frequency in hospitals - PowerPoint PPT Presentation

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Clinical errors - their causes and frequency in hospitals

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Clinical errors - their causes and frequency in hospitals Prof Johanna Westbrook Prof Enrico Coiera Funded by: HCF Health & Medical Research Foundation – PowerPoint PPT presentation

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Title: Clinical errors - their causes and frequency in hospitals


1
Clinical errors - their causes and frequency in
hospitals Prof Johanna Westbrook Prof Enrico
Coiera Funded by HCF Health Medical Research
Foundation
2
Problem
  • High rates of medical errors and adverse events
  • 16 of admissions in Aust experience an adverse
    event
  • 51 of these were judged to be preventable
  • Cost in additional bed-days alone of these errors
    is estimated at 5 of the health budget.
  • (Quality in Australian Health Care Study, Wilson
    et al., 1995)

3
Medication Errors
  • In Australia 2 inpatients experience
  • harm or death due to medication errors
  • Estimated errors in 20 of all drug doses
    administered in hospital
  • IV medications have error rates of 50-90
  • Only 1 Australian study 20 error rate in IVs 2
    surgical wards

4
Communication load
  • High communication loads
  • 80 of time in communication
  • Interrupted on average 15/hour

5
Percentage of time nurses spent in different work
tasks (N244 hours of observation)
6
Which clinical task is most likely to be
interrupted?
  • 25 of all interruptions occurred while nurses
    were preparing or administering medications

7
  • Interruptions add to cognitive load, stress and
    reduce decision-making performance
    Errors

8
Aim
  • To examine the relationships between clinicians
    cognitive communication loads and two types of
    errors
  • Medication administration errors
  • Task scheduling errors eg forget tasks, task
    completion delayed or incomplete

9
Hypotheses
  • Being interrupted while preparing or
    administering a drug increases the likelihood of
    a medication error
  • Interruptions multi-tasking in high stress
    clinical environments increase task scheduling
    errors (ie tasks are left incomplete, delayed or
    forgotten)
  • Clinical experience may compensate for the
    effects of a high communication load

10
Medication Administration Errors
  • Watch nurses as they prepare administer IV
    medications
  • Record interruptions
  • Compare observed data with patients charts to
    identify errors

11
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12
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13
Drs observation study
  • Follow Drs for 2hr blocks and record
  • Work tasks
  • Interruptions
  • Multi-tasking
  • Ask about
  • What tasks next?
  • How stressed?

14
Outcomes
  • Rates type of IV medication administration
    errors
  • Determine relationship between interruptions and
    medication errors
  • By error type and nurse experience
  • Measure association of cognitive and
    communication load and task scheduling errors
  • Eg Average time taken to return to interrupted
    tasks
  • Recovery from interruptions by clinician
    experience

15
Importance
  • Baseline data to test any interventions designed
    to reduce medication errors
  • New data about clinicians communication loads
    and errors, first step in designing effective
    interventions to support clinicians work.
  • Establishing links between researchers health
    insurance industry
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