Hospital errors

See, for example, "U.S. Hospital Errors Continue to Rise," Washington Post, April 2, 2007. Viewed at www.washingtonpost.com. 

Where did the error orcur (eg, hospital, outpatient or retail pharmacy, nursing home, patient s home) ... 

Meanwhile, these chemicals—like chemical agents encountered at work or in hobbies or as pollutants in air, water, soil, or food—can also cause harm. Sometimes the known mechanisms of action permit us to predict the nature of toxicity to be expected. A meta-analysis of prospective studies from U.S. hospitals indicates that 6.7% of in-patients have serious adverse drug reactions 0.3% have fatal reactions (Lazarou et al., 1998). In fact, estimates of 40,000 to 100,000 deaths per year attributed to errors in medical care, primarily due to adverse reactions to pharmaceuticals, make this phenomenon a major cause of death in the United States (Meyer, 2000). A tremendous... 

Recently, the pesticide company experienced two accidents. The first accident was a small fire of a mixture of liquid pressurised gas and liquid pesticide, which resulted in some material damage. The second accident was an instantaneous release of pesticide powder, which resulted in a number of operators requiring treatment for respiratory problems in a local hospital. Management recognised that safety problems had to be addressed. Additionally, a major concern for the company was the high financial penalties which resulted from late deliveries. Both the safety and the reliability of the operational process had to be improved. The management thought that operator errors were the cause of almost all the problems in the process. 

Box 7.1 Starting point for reducing medication errors in hospitals... 

Patients, in particular the elderly, are moved between different settings in the health care system. Medicines are involved in most of the stages of the journey. This includes home to hospital, home to care home or hospice, home to day centre, hospital to home, hospital to care home or hospice, ward to ward in hospital, hospital to hospital, care home to home, care home to care home. Especially on admission to, and discharge from, hospital there are several factors that can lead to errors. 

Experience from hundreds of organisations has shown that poor communication of medical information at transition points is responsible for as many as 50% of all medication errors in the hospital and up to 20% of adverse drug events (IHI MedReconcilliation 2008). In our different settings at a university and county hospitals, we had errors in 40-85% of the elderly patients before starting a new practice. 

The knowledge and application of pharmaceutical and clinical calculations are essential for the practice of pharmacy and related health professions. Many calculations have been simplified by the shift from apothecary to metric system of measurements. However, a significant proportion of calculation errors occur because of simple mistakes in arithmetic. Further, the dosage forms prepared by pharmaceutical companies undergo several inspections and quality control tests. Such a luxury is almost impossible to find in a pharmacy or hospital setting. Therefore it is imperative that the health care professionals be extremely careful in performing pharmaceutical and clinical calculations. In the present chapter, a brief introduction is provided for the three systems of measurement and their interconversions ... 

A recent report by the Inshtute of Medicine (lOM), To Err is Human, Building a Safer Health System, claims that an3rwhere from 44,000 to 98,000 people die each year as a result of preventable medical errors. Many of these adverse events are associated with the use of pharmaceuhcals and are potenhally preventable. The lOM estimates that in the United States more than 7000 deaths occur annually as a result of preventable medication errors. In addihon, preventable medicahon errors are estimated to increase hospital costs by about 2 billion nationwide. ... 

Cincinnati Children s Hospital Medical Center, the 2003 recipient of the prestigious Healthcare Information Management and Systems Society s (HIMSS) Nicholas E. Davies Award of Excellence for Electronic Health Record (eHR), was able to reduce medication errors by 35% and decrease medication turnaround time by 52% through the use of an integrated clinical information system. 

That medication errors occur frequently in U.S. hospitals has been well-documented [2-4]. In observation studies done between 1962 and 1995 on the rate of administration errors in a variety of in-patient settings, rates ranged from 0 to 59% [5]. Estimates that medication errors occur in almost 7% of hospitalized patients have been reported [6]. One study found that the frequency of medication errors was 1.4 per admission [4]. When approximately 290,000 medication orders were analyzed, Lesar et al. estimated that there were almost two serious errors for every 1,000 orders written. Based on a review of death certificates, it was estimated that almost 8,000 people died from medication errors in 1993, as opposed to almost 3,000 people in 1983 [3]. Researchers foimd an error rate at tv 0 children s hospitals of 4.7 per 1,000 orders [7]. Several... 

Medication errors are costly to both the patient (direct costs such as additional treatment and increased hospital stay) and to society (indirect costs such as decreased employment, costs of litigation) [1,5]. The cost of medication errors in a 700-bed teaching hospital based on a study in eleven medical and surgical units in two hospitals over a six-month period, was estimated to be 2.8 million dollars annually [2]. The increased length of stay associated with a medication error was estimated to be 4.6 days [2]. In a four-year study of the eosts of adverse drug events (ADEs) in a tertiary care center, 1% of these events were elassified as medication errors. The excess hospital costs for ADEs over the study period were almost 4,500,000 with almost 4,000 days of increased hospital stay [12]. 

A hospital trolley developed by Bayer and GMP is described. The trolley is equipped with a portable computer for the collection and management of patient information with the aim of reducing medical errors. The main component is a sandwich stracture reaction injection monlded in Bayer s Baydnr 60 PU and consisting of a cellnlar core and a smooth skin. Other components are made of PP, PMMA or polycarbonate. Developments by GMP in the nse of PU foams in refrigerator manufacture are also reviewed, and tnmover fignres are presented for the Company. 

FoUi HL, Poole RL, Benitz WE, Russo JC. Medicatiou error prevention by clinical pharmacists in two children s hospitals. Pediatrics 1987 79(5) 718-22. 

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