Multidisciplinary approaches to reducing error and risk in a patient care setting (original) (raw)

Overview of medical errors and adverse events

Annals of Intensive Care, 2012

Safety is a global concept that encompasses efficiency, security of care, reactivity of caregivers, and satisfaction of patients and relatives. Patient safety has emerged as a major target for healthcare improvement. Quality assurance is a complex task, and patients in the intensive care unit (ICU) are more likely than other hospitalized patients to experience medical errors, due to the complexity of their conditions, need for urgent interventions, and considerable workload fluctuation. Medication errors are the most common medical errors and can induce adverse events. Two approaches are available for evaluating and improving quality-of-care: the room-for-improvement model, in which problems are identified, plans are made to resolve them, and the results of the plans are measured; and the monitoring model, in which quality indicators are defined as relevant to potential problems and then monitored periodically. Indicators that reflect structures, processes, or outcomes have been developed by medical societies. Surveillance of these indicators is organized at the hospital or national level. Using a combination of methods improves the results. Errors are caused by combinations of human factors and system factors, and information must be obtained on how people make errors in the ICU environment. Preventive strategies are more likely to be effective if they rely on a system-based approach, in which organizational flaws are remedied, rather than a human-based approach of encouraging people not to make errors. The development of a safety culture in the ICU is crucial to effective prevention and should occur before the evaluation of safety programs, which are more likely to be effective when they involve bundles of measures.

Medication Errors: Preventing Untimely Deaths

International Journal of Research in Nursing, 2014

Medication adverse events play a huge role in hospital deaths and morbidity in the US. This plays a large role in the public health of the US at large. Health education is a primary target for those taking medications. A quality assurance or improvement program that is appropriate to capture drug events and measure quality data is essential to prevent these untimely and mostly preventable deaths. This study examines medication errors, the cause and effect and what leaders can do to prevent untimely patient deaths.

Profiles in Patient Safety: When an Error Occurs

Academic Emergency Medicine, 2004

Medical error is now clearly established as one of the most significant problems facing the American health care system. Anecdotal evidence, studies of human cognition, and analysis of high-reliability organizations all predict that despite excellent training, human error is unavoidable. When an error occurs and is recognized, providers have a duty to disclose the error. Yet disclosure of error to patients, families, and hospital colleagues is a difficult and/or threatening process for most physicians. A more thorough understanding of the ethical and social contract between physicians and their patients as well as the professional milieu surrounding an error may improve the likelihood of its disclosure. Key among these is the identification of institutional factors that support disclosure and recognize error as an unavoidable part of the practice of medicine. Using a case-based format, this article focuses on the communication of error with patients, families, and colleagues and grounds error disclosure in the cultural milieu of medial ethics.

Patient Safety—Ten Years Later

Journal of PeriAnesthesia Nursing, 2010

December 1, 2009 was the tenth anniversary of To Err is Human, 1 the Institute of Medicine (IOM) report on medical errors in the health care system. Dr. Wachter notes that this report "arguably launched the modern patient-safety movement." 2 In an updated analysis, Wachter looks at the progress that has been made since that initial report and also gives an in-depth description of the gaps that are still present. How would you grade patient safety progress over the past ten years? In this article, Wachter looks at ten domains of patient safety and assigns a grade representing progress, or lack of progress in the area. See Box 1. Wachter's overall grade for progress is a Be, better than the C1 he gave it in 2004. 2 You can read Dr. Wachter's article for details, but there were a few important points I want to discuss.

Medication errors during medical emergencies in a large, tertiary care, academic medical center

Resuscitation, 2012

Purpose: Evaluate the rate, type and severity of medication errors occurring during Medical Emergency Team (MET) care at a large, tertiary-care, academic medical center. Methods: A prospective, observational evaluation of 50 patients that required MET care was conducted. Data on medication use were collected using a direct-observation method whereby an observer documented drug information such as drug, dose, frequency, rate of administration and administration technique. Subsequently, a team of three clinicians assessed rate, type and severity of medication errors using definitions consistent with United States Pharmacopeia MEDMARX system. Severity was assessed on a scale of minor, moderate and severe. Results: One hundred eighty six doses were observed for 36 different medications. A total of 296 errors were identified; of these 196 errors (66%) were inappropriate aseptic technique. Of the remaining 100 errors, 46% were prescribing errors, 28% administration technique errors, 14% mislabeling errors, 10% drug preparation errors and 2% improper dose prescribing. Examples included: (1) prescribing errors, (2) administering wrong doses, (3) mislabeling, and (4) wrong administration technique such as not flushing intravenous medication through intravenous access. The rate of medication administration errors was 1.6 errors/dose including aseptic technique and 0.5 errors/dose excluding aseptic technique. A notable portion (14%) of errors was considered at least moderate in severity. Conclusions: One out of 2 doses was administered in error after errors of using inappropriate aseptic technique were excluded. There is a need for education and systematic changes to prevent medication errors during medical emergencies as an effort to avoid harm.