Medical Errors: An Ongoing Threat to Quality Health Care

Medical errors: adverse events that could have been prevented given current state of medical knowledge
Medication error: preventable event causing or leading to inappropriate medication use or patient harm
Medication in control of health care professional, patient, or consumer
Adverse events: adverse changes in health occurring as a result of treatment
Adverse drug event when medications involved
Seminal Research and Medical Errors #1
Benchmark study by Brennan et al. (1991)
Study by Thomas et al. (1999)
Study by Leape et al. (1991 and 1994)

 

Seminal Research and Medical Errors #2
“To Err Is Human” by the Institute of Medicine (IOM)
Death due to medical errors: possibly eighth leading cause of death in 1999
More people die yearly from medical errors than from motor vehicle accidents, breast cancer, or AIDS
Examination of types of errors: adverse events with pharmaceutical agents (potentially preventable)
Studies confirming IOM figures
Confirmation of scope of medical errors in follow-up report by IOM

 

Seminal Research and Medical Errors #3
IOM recommendations:
National goal to reduce medical errors by 50% over 5 years
Four-pronged approach to reducing medical mistakes nationwide (see Box 14.1)
National focus
Identification of, and learning from, errors
Elevation of standards, expectations for improvement
Implementation of safe practices

 

Question #1
Is the following statement true or false?
Adverse events result from treatment.

 

Answer to Question #1
True
Adverse events are defined as adverse changes in health that occur as a result of treatment.

 

Work to Achieve IOM Goals #1
Quality Interagency Coordination Task Force (1998)
Coordination of federal agencies providing health care services
Evaluation of IOM recommendations
Development of strategies for identifying threats to patient safety, reducing medical errors
Final report delivered in February 2000

 

Work to Achieve IOM Goals #2
National Forum for Health Care Quality Measurement and Reporting (2017)
The National Quality Strategy: Aims, Priorities, and Levers
Aims
Better care
Healthy people/Healthy communities
Affordable care

 

Work to Achieve IOM Goals #3
The National Quality Strategy: Aims, Priorities, and Levers (see Box 14.3)
Six priorities
Eight levers

 

Work to Achieve IOM Goals #4
Joint Commission 2017 National Patient Safety Foundation (see Box 14.4)
Improve patients correctly
Improve staff communication
Use medicines safely
Use alarms safely
Prevent infection
Identify patient safety risks
Prevent mistakes in surgery

 

Work to Achieve IOM Goals #5
The Joint Commission
Comprehensive database of sentinel events
Root cause analysis; Sentinel Events Policy
Failure mode and effects analysis (FMEA)

 

Work to Achieve IOM Goals #6
Centers for Medicare and Medicaid Services (formerly HCFA)
Medicare Quality Initiatives
Pay for Performance (quality-based purchasing)
Physician Quality Reporting Initiative; became Physician Quality Reporting System with passage of Affordable Care Act of 2011
PQRS transitioned to the Merit-based Incentive Payment System (MIPS) under the Quality Payment Program (Quality Payment Program, 2017)

 

Work to Achieve IOM Goals #7
Centers for Medicare and Medicaid Services (formerly HCFA)
Medicare Improvements for Patients and Providers Act (2008)
“Never events” (see Box 14.5)

 

Work to Achieve IOM Goals #8
Institute for Healthcare Improvement
Highlighting of evidence-based best practices
Disciplined research and development processes, prototyping projects
Facilitation of further research, adaptation, and adoption of quality improvement strategies
Health care report cards

 

Question #2
The National Priorities Partnership evolved out of which of the following?
A. Quality Interagency Coordination Task Force
B. Centers for Medicare and Medicaid Services
C. National Forum for Health Care Quality Measurement and Reporting
D. The Floyd D. Spence National Defense Authorization Act of 2001

 

Answer to Question #2
C
The National Priorities Partnership developed from the work of the National Forum for Health Care Quality Measurement and Reporting.

 

Culture of Safety Management
Patient safety: one of nation’s most pressing challenges
Mandate for every health care organization
IOM final recommendation: implementation of safe practices at delivery level

 

Six Sigma Approach
Culture of safety management at institutional level
Sigma: statistical measurement reflecting product or process performance
Higher sigma values = better performance
Historically, health care aiming for three-sigma processes instead of six

 

Mandatory Reporting of Errors
Mandatory reporting system for medical errors, adverse events at national, state levels
As of 2014, at least 26 states requiring hospitals and/or other medical facilities to report serious medical errors
Need for increased mandatory reporting at institutional level and by individual providers
Possible fear of legal suits or disciplinary measures as barrier for greater disclosure and reporting

 

Legal Liability and Medical Error Reporting
Medical liability system + litigious society: potential barriers to systematic efforts to uncover, learn from mistakes
Patient Safety Improvement Act (2002)
Patient Safety and Quality Improvement Act of 2005
Proposed federal legislation to protect voluntary reporting of ordinary injuries, “near misses”

 

Leapfrog Group
Need for implementation of evidence-based standards such as
Computerized physician (or prescriber) order entry (CPOE)
Leapfrog developed evaluation tool
Evidence-based hospital referral (EHR)
Intensive-care-unit physician staffing (IPS)

 

Question #3
Is the following statement true or false?
A sigma value of three indicates lower performance than a sigma value of five.

 

Answer to Question #3
True
A sigma value is a statistical measurement that reflects performance. Thus, the higher the sigma value, the better the performance.

 

Bar Coding Medications
Reduction in point-of-care medication errors
National drug code number for all prescription, OTC meds used in hospitals
Bar coding + CPOE = increased ability to follow “five rights” of medication admin

 

Changing Organizational Culture
Quality and Safety Education for Nurses (QSEN) project
Knowledge, skills, and attitudes (KSA) necessary to continuously improve the quality and safety of the health care system
KSA—better able to identify potential errors and intervene before errors occur
Organizational cultures needing to remove blame from individual and focus on how organization can be modified to reduce likelihood of errors
“Just culture” or “culture of safety management”

 

Patient Safety Solutions
WHO’s Word Alliance for Patient Safety and the Collaborating Centre packaged nine effective solutions called patient safety solutions to reduce health care errors
WHO (2017) initiated its third Global Patient Safety Challenge: Medication Without Harm
See Box 14.6

 

Question #4
Which of the following would most likely be most significant in promoting a culture of safety management?
A. Mandatory reporting of errors
B. Six Sigma approach
C. Bar coding meds
D. Removal of blame

 

Answer to Question #4
D
Although mandatory reporting of errors, a Six Sigma approach, and bar coding meds are important in promoting a culture of safety management, perhaps the most significant change that must occur is that organizational cultures must be created that remove blame from the individual and focus on how the organization can be modified to reduce the likelihood of errors occurring in the future.

No Comment.