Measuring medical errors

Revere L, Black K. Integrating Sis Sigma with total quality management a case example for measuring medication errors. J Healthc Manag. 2003 48 ... 

Process-based methods for measuring medication errors... 

Three methods for measuring medication errors have been used in most medication error research spontaneous reporting, chart review and... 

PDF must have a cost-effective drug utilization management program, quality assurance measures, medication error reduction systems, and a program to combat and recognize fraud, waste, and abuse. 

Van Den Bos J. Rustagi K, Gray T. Halford M. Ziemkiewicz E. Shreve J The 17.1 billion problem the annual cost of measurable medical errors. Health Aff 2011 30 596-603. Pennsylvania Patient Safety Authority Quarterly update on the preventing wrong-site surgery project. PA Patient Saf Advis 2010 7 108-110. 

ADEs and medication errors can be extracted from practice data, incidents reports from health professionals, and patient surveys. Practice data include charts, laboratory, prescription data, and administrative databases, and can be reviewed manually or screened by computer systems to identify signals. A method of ADE and medication error detection and classification has been presented that is feasible and has good reliability (Marimoto et al. 2004). It can be used in various clinical settings to measure and improve medication safety. 

Practitioners and consumers often want to know the acceptable medication error rate. There is no benchmark. A zero error rate is desired, but unattainable because of human factors. If organizations can determine measuring points and consistently follow them, it might be possible to determine an internal benchmark to be used for quality improvement purposes. However, because the parameters of the measurement are unlikely to be duplicated elsewhere, use of the number for external comparisons is not valid. 

The lack of photoprotection for the drug product during administration may lead to increased/decreased efficacy or increased toxicity of photolabile drugs. These episodes may be categorized as preventable medication errors, in particular, as wrong administration-technique errors (2). On the other hand, superfluous photoprotection measurements represent an unproductive use of nurses time and a waste of materials. 

Other medication errors involving medicationdispensing devices reported to the USP have included the interchange of devices supplied with specific products. Each device packaged with a medication is calibrated for that medication based on the viscosity and concentration of the specific liquid it delivers. These devices are not calibrated in any standardized way some are measured in milligrams (mg), others in... 

To enhance the quality, appropriateness, and effectiveness of health care services, and access to these services the federal government in the Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239) established the AHCPR. The act, sometimes referred to as the Patient Outcome Research Act, called for the establishment of a broad-based, patient-centered outcomes research program. In addition to the traditional measures of survival, clinical endpoints and disease- and treatment-specific symptoms and problems, the law mandated measures of functional status and well-being and patient satisfaction. In 1999, then President Clinton signed the Healthcare Research and Quality Act, reauthorizing AHCPR as the AHRQ until the end of fiscal year 2005. Presently, its mission is to improve the outcomes and quality of health care, reduce its costs, address patient safety and medical errors, broaden access to effective services, and improve the quality of health care services. 

Indicators provide a quantitative measure of an aspect of patient care that can be used in monitoring, evaluating, and improving the quality and appropriateness of healthcare delivery. An indicator may serve as a screen or red flag to identify a potential problem (postoperative infection rate, number of serious medication errors) or measure progress toward an established goal (percent of patients with atrial fibrillation who are anticoagulated). 

The two major types of performance measures are 1) rate-based performance measures, which measure an event for which a certain proportion of the events are expected to occur even with quality care (such as mistimed prescription refills) and 2) sentinel-event performance measures, which measure a serious event that requires an indepth review for each occurrence of the event (such as a medication error).To provide meaningful information, performance measures must be... 

C. difficile. Of the nine safety indicators (Figure 6.2), seven showed an increase which apparently indicated that care was less safe or, more probably, better coding. For medication errors, adverse drug events and indeed most other safety issues in the NHS, we simply have no idea of long-term trends. The fact that we simply do not know whether patients are safer suggests that much more attention needs to be paid to measurement and evaluation in the next ten years than has been the case in the previous 10 years. 

Medical errors 2. Iatrogenic diseases 3. Hospitals-Safety measures. I. Title. 

In 2005, CPSI launched fhe "Safer Healthcare Now" campaign to reduce medical error-related injuries by focusing on a number of evidence-based measures. 

Medical errors—Prevention. 2. Health services administrators. 3. Patients—Safety measures. 1. Hidley, John H. II. Title. 

There are variants that need to be added to these parameters which can hardly be used at a non medical level. These are minimum toxic doses or concentrations and minimum iethai concentrations or doses (MLC, MLD). The last two are mentioned without using them later on, but given the important level of error regarding LC and LD50 measurements, MLC and MLD can nevertheless be used as a reference. 

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