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Course Sample:
Introduction Medical error reduction and patient safety are the buzzwords in healthcare. The release of the Institute of Medicine Report To Err is Human: Building a Safer Health System 1 in 1999 signaled a change in the delivery healthcare. Since the release of To Err is Human, patient safety legislation has been discussed on the federal and state levels, patient safety guidelines have been adopted by accreditation organizations, and patient safety and the reduction of medical errors has received a lot of publicity and press. Healthcare consumers are encouraged to become actively involved in the services provided by their physicians and hospitals in order to decrease the risk of medical errors associated with receiving the wrong medication or experiencing the side effects associated with multiple medication use. The medical error statistics quoted in the Institute of Medicine Report, To Err is Human: Building a Safer Health System, hereinafter called The IOM Report, are alarming as it was estimated that as many as 98,000 people die in hospitals from medical errors and that medication errors account for 1 out of 131 outpatient deaths and 1 out of 854 in patient deaths. 2 In a survey conducted by HcPro, a healthcare consulting firm in partnership with the healthcare publication "Briefings on Patient Safety", 300 healthcare professionals responded that 95 deaths occurred in their facilities from medical errors within the last year and 29 of the deaths were attributable to medication errors. 3 Deaths were also associated with operative and postoperative complications. The three most frequent medical errors in the survey were medication errors, patient falls, and delay in treatment. What is a Medical Error? A medical error is defined as the failure of a planned action to be completed as intended which is an error of execution or the use of a wrong plan to achieve an aim, which is an error of planning. 4 An adverse event is an injury caused by medical management rather than by the underlying disease or condition of the patient. 5 The most common adverse events in healthcare are drug complications, wound infections, and technical complications. 6 Medical errors and adverse events are not the same because not all adverse events are the result of a medical error. In the literature, preventable medical errors are commonly referred to as preventable adverse events. Preventable adverse events include errors associated medication administration, restraint related injuries or deaths, hospital-acquired or treatment-related infections, falls, burns, pressure ulcers, wrong-site surgery and surgical injuries, transfusions reactions, and errors related to mistaken identity. 7 Most of the research involving medical errors involves reviewing occurrences in hospitals. An occurrence is any deviation from the medical treatment regimen in the care provided to a patient. However, additional research in settings other than the hospital environment is needed with the decrease in the length of hospital stay, the increased acuity of nursing home and home health care patients, the complexity of services performed in ambulatory care settings, and the proliferation of high-tech services performed in the home care environment. Why Do Medical Errors Occur in Healthcare? Healthcare delivery involves a complex system of processes, individuals, and departments. Risk is inherent in the delivery of healthcare because of the interplay of the various healthcare professionals and paraprofessionals and the number of departments in a given facility. A systems approach of the processes associated with healthcare delivery is needed to decrease medical errors. 8 The delivery of safe healthcare requires the appropriate managerial decisions, the appropriate equipment that is well-maintained and reliable, a skilled workforce, up to date policy and procedures, reasonable work schedules and patient care assignments, well-designed position descriptions, and clear guidance of desired and undesired performance. 9 These are preconditions for the safe delivery of healthcare and if absent can lead to medical errors. For example, Sam Smith, a pharmacist was recently hired by Memorial Hospital. Although Sam is a new graduate, he worked at the hospital as a pharmacy intern and as a pharmacist technician while completing his formal pharmacy training. Memorial Hospital has a four-month orientation program for new graduate pharmacists where the new graduate is mentored and precepted by another pharmacist on every shift that the new pharmacist works. Sam worked 7 a.m. to 7 p.m. for five consecutive days and he was precepted by Tom Thompson, a licensed pharmacist with nine years of experience. After his fifth week in the pharmacy orientation program, Sam is scheduled to work alone on the sixth day from 11 p.m. to 7 a.m. because there was a shortage of pharmacists at the hospital. Sam failed to review a doctor's order correctly and provides Mary Middle, RN with the incorrect dosage of Ampicillin for a newborn. Mary, who was assigned to care for 20 patients on an adult and pediatric medical-surgical unit did not catch the medication error even though the syringe was labeled incorrectly. The medical-surgical unit has 33 patients and the other 13 patients were assigned to an L.P.N. The RN, Mary administers the medication. The precondition of reasonable work schedules and adherence to facility policy and procedures was highlighted in this example. The work schedule of the graduate pharmacist and the patient load of nurse are a reality in some healthcare organizations today. Pharmacist Sam worked a total of sixty-six hours in a seven-day period when the normal work week is 40 hours a week. Do you think the work schedule of Pharmacist Sam was reasonable? Do you think that the assignment for Nurse Mary was reasonable? This hypothetical situation also underscores the need for a systems approach in confronting medical errors. Typically, an incident report(s) would have been written and the individual practitioners would have been counseled or even disciplined for medication error. The nursing manager of the medical-surgical unit would counsel the nurse while the pharmacy director would counsel the pharmacist. The patient was not injured here so it is questionable as to whether the family of the newborn would have been informed by the hospital. Since the patient was not injured, there is little risk of a claim or lawsuit. Professionals in the risk management or quality improvement department may not review this error until a later time. |
