Medication errors reduction

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. 

Policy makers, practitioners, and scholars from a variety of disciplines have recently embraced a new approach to risk reduction in health care—a "systems approach"—without proposing any specific reforms of medical liability law. The Institute of Medicine (IOM) placed its imprimatur on this approach in its recent reports (Kohn et al., 2000 IOM, 2001). In its simplest form, a systems approach to risk reduction in health care posits that an injury to a patient is often the manifestation of a latent error in the system of providing care. In other words, a medical mishap is the proverbial "accident waiting to happen" because the injury-preventing tools currently deployed, including medical liability law, are aimed at finding the individuals at fault rather than the systemic causes of error. Coexistence of a systems approach to error reduction and medical liability law as a conceptual framework for policy makers implies that the latter is likely to evolve in an incremental fashion as the former makes more visible different aspects of the medical error problem. 

The public took notice in 1999 when the Institute of Medicine (IOM) released a report, To Err Is Human Building a Safer Health System. According to the report, between 44,000 and 98,000 deaths may result each year from medical errors in hospitals alone. And more than 7,000 deaths each year are related to medications. In response to the IOM s report, all parts of the U.S. health system put error reduction strategies into high gear by re-evaluating and strengthening checks and balances to prevent errors. 

It s a promising way to automate aspects of medication administration, says Robert Krawisz, former executive director of the National Patient Safety Foundation. The technology s impact at VA hospitals so far has been amazing. The Department of Veterans Affairs (VA) already uses bar codes nationwide in its hospitals, and the result has been a drastic reduction in medication errors. For example, the VA medical center in Topeka, Kan., has reported that bar coding reduced its medication error rate by 86 percent over a nine-year period. 

Currently, many pharmacies have an ineffective approach to error reduction. Investigations that occur during the error reporting process tend to focus their attention on the front end or active end of the error such as the front-line practitioner (e.g., a technician preparing a prescription or a pharmacist dispensing the medication). Human nature tends to assign blame to these front-line practitioners involved in medication errors. It is easier and in our nature to blame individuals and resort to familiar solutions disciplinary action, individual remedial education, placing error information... 

Research methods on medication error data are not standardized. Therefore, they are subject to some limitations in generalizability. Because widespread interest in developing scientific approaches for reducing medication error is relatively recent, there are few well-established methods for conducting research in this held. However, funding for research in safe medication use and error reduction is available from several public and private sources, including the Agency for Healthcare Research and Quality. 

To identify opportunities for reducing medication errorS/ it is important that each error be carefully reviewed by a limited number of individuals to gain intimate knowledge of each reported incident. Collection and classification of error data must be followed by use of a careful epidemiological approach to problem solving at the system level. Narrative data which may not be seen by looking at the categorical data alone/ can be used to provide important details about proximal causes and latent error that may have contributed to the event. Success in this type of error reduction requires the reviewers to read between the lineS/ look for common threads between reports/ and link multiple errors that are the result of system weaknesses. 

Miller MR, Robinson KA, Lubomski LH, et al. Medication errors in paediatric care a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations. Qual Saf Health Care 2007 16 116-126. 

The analysis of harmful spontaneous medication error reports is a popular and cost-effective method for identifying harmful medication errors in order to propose an error reduction strategy. Cousins et al. (2002) conducted an analysis of reviewed press reports over an 8-year period. This is a very cost-effective approach to identifying serious and harmful medication errors, but it is unable to provide information on epidemiology. 

Cimino et al, 2004 (USA) 2 weeks pre-intervention 3 month site-specific error reduction interventions 2 weeks post-intervention Paediatric hospitals - 9 PICUs Prospective study Three levels of surveillance used (1) pharmacy order review for errors and computer order entry step (2) PICU nurse order transcription and review for errors step (3) an oversight team check Sample = 12 026 medication orders ror rate 0.22 per order... 

Organisations still frequently rely on retrospective techniques such as incident reporting and complaints to drive safety management [21] and healthcare has been slow and sporadic in adopting predictive safety assessment techniques to detect medical error [22]. Twenty two percent of people in the UK believe, when asked, that they have been the victim of medical error [23]. Nevertheless continually striving to protect patients at vulnerable points in their lives is stiU clearly the right thing to do and a move from reactive to proactive risk reduction wiU surely pay dividends in the future. 

Figure 6.8 shows a reduction in medication errors that leaders at Memorial Hermann attribute to the system of reporting and analysis. The lessons from the case studies illustrate that reporting systems should be developed according to the imique needs of each organization. All reporting systems, however, should follow the auditing model depicted in Figure 6.9. As the figure shows, deaths are the least ffequendy reported occurrences, whereas variances in practice are the most fre-quendy reported. The frequency of adverse event and near miss reports should...

One Froedtert project focused on reducing errors associated with insulin. Insulin error reduction was chosen for several reasons. Insulin has been identified as a high-alert medication by the Institute for Safe Medication Practices and has been the subject of several JCAHO sentinel event alerts. Recent literature supported improved glycemic management associated with decreased mortality, complications, and infections (van den Berghe and others, 2001). Froedtert also had identified internal opportunities for improvement, and several Froedtert physician groups had expressed interest. 

Froedtert now plans to become a "Six Sigma Organization," which involves expanding the use of the Six Sigma methodology to encompass reduction of medical errors, promotion of patient safety, cost reduction, and enhancement of process efficiency. 

The leaders able to change their reactions to error are the ones able to advance a culture of safety. The Minnesota Alliance for Patient Safety (2002) defined reduction of medical error as a leadership imperative and an executive responsibility that cannot be delegated. These leaders identified the following requirements to advance safety ... 

Patient safety is a major concern in heaith care systems woridwide. Patients with serious conditions, muitimorbidity, and with intense and fragmented health care utilization, like end-stage renal disease (ESRD) patients, are at increased risk for suffering adverse events. In this chapter, the fundamental terms and concepts of patient safety are introduced. Essential epidemiological data relating to the frequency of adverse events and medical errors are provided. The chapter reports important safety threats for ESRD patients and describes examples of key innovations which contribute to patient safety. Recommendations and risk reduction strategies to improve care of ESRD patients are presented. 

IHI has produced a full package for improvement with tool kits, follow up measures on all aspects on Medication Reconciliation. Based on different strategies and settings they also report an error rate reduction of at least 50% (IHI MedReconcilliation 2008)... 

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