4 Medical Errors: An Ongoing Threat to Quality Health Care

Chapter 14 Medical Errors: An Ongoing Threat to Quality Health Care

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Definitions

Medical errors: adverse events that could have been prevented given current state of medical knowledge

Medication error: preventable event causing or leading to inappropriate medication use or patient harm

Medication in control of health care professional, patient, or consumer

Adverse events: adverse changes in health occurring as a result of treatment

Adverse drug event when medications involved

Seminal Research and Medical Errors #1

Benchmark study by Brennan et al. (1991)

Study by Thomas et al. (1999)

Study by Leape et al. (1991 and 1994)

Seminal Research and Medical Errors #2

“To Err Is Human” by the Institute of Medicine (IOM)

Death due to medical errors: possibly eighth leading cause of death in 1999

More people die yearly from medical errors than from motor vehicle accidents, breast cancer, or AIDS

Examination of types of errors: adverse events with pharmaceutical agents (potentially preventable)

Studies confirming IOM figures

Confirmation of scope of medical errors in follow-up report by IOM

Seminal Research and Medical Errors #3

IOM recommendations:

National goal to reduce medical errors by 50% over 5 years

Four-pronged approach to reducing medical mistakes nationwide (see Box 14.1)

National focus

Identification of, and learning from, errors

Elevation of standards, expectations for improvement

Implementation of safe practices

Question #1

Is the following statement true or false?

Adverse events result from treatment.

Answer to Question #1

True

Adverse events are defined as adverse changes in health that occur as a result of treatment.

Work to Achieve IOM Goals #1

Quality Interagency Coordination Task Force (1998)

Coordination of federal agencies providing health care services

Evaluation of IOM recommendations

Development of strategies for identifying threats to patient safety, reducing medical errors

Final report delivered in February 2000

Work to Achieve IOM Goals #2

National Forum for Health Care Quality Measurement and Reporting (2017)

The National Quality Strategy: Aims, Priorities, and Levers

Aims

Better care

Healthy people/Healthy communities

Affordable care

Work to Achieve IOM Goals #3

The National Quality Strategy: Aims, Priorities, and Levers (see Box 14.3)

Six priorities

Eight levers

Work to Achieve IOM Goals #4

Joint Commission 2017 National Patient Safety Foundation (see Box 14.4)

Improve patients correctly

Improve staff communication

Use medicines safely

Use alarms safely

Prevent infection

Identify patient safety risks

Prevent mistakes in surgery

Work to Achieve IOM Goals #5

The Joint Commission

Comprehensive database of sentinel events

Root cause analysis; Sentinel Events Policy

Failure mode and effects analysis (FMEA)

Work to Achieve IOM Goals #6

Centers for Medicare and Medicaid Services (formerly HCFA)

Medicare Quality Initiatives

Pay for Performance (quality-based purchasing)

Physician Quality Reporting Initiative; became Physician Quality Reporting System with passage of Affordable Care Act of 2011

PQRS transitioned to the Merit-based Incentive Payment System (MIPS) under the Quality Payment Program (Quality Payment Program, 2017)

Work to Achieve IOM Goals #7

Centers for Medicare and Medicaid Services (formerly HCFA)

Medicare Improvements for Patients and Providers Act (2008)

“Never events” (see Box 14.5)

Work to Achieve IOM Goals #8

Institute for Healthcare Improvement

Highlighting of evidence-based best practices

Disciplined research and development processes, prototyping projects

Facilitation of further research, adaptation, and adoption of quality improvement strategies

Health care report cards

Question #2

The National Priorities Partnership evolved out of which of the following?

A. Quality Interagency Coordination Task Force

B. Centers for Medicare and Medicaid Services

C. National Forum for Health Care Quality Measurement and Reporting

D. The Floyd D. Spence National Defense Authorization Act of 2001

Answer to Question #2

The National Priorities Partnership developed from the work of the National Forum for Health Care Quality Measurement and Reporting.

Culture of Safety Management

Patient safety: one of nation’s most pressing challenges

Mandate for every health care organization

IOM final recommendation: implementation of safe practices at delivery level

Six Sigma Approach

Culture of safety management at institutional level

Sigma: statistical measurement reflecting product or process performance

Higher sigma values = better performance

Historically, health care aiming for three-sigma processes instead of six

Mandatory Reporting of Errors

Mandatory reporting system for medical errors, adverse events at national, state levels

As of 2014, at least 26 states requiring hospitals and/or other medical facilities to report serious medical errors

Need for increased mandatory reporting at institutional level and by individual providers

Possible fear of legal suits or disciplinary measures as barrier for greater disclosure and reporting

Legal Liability and Medical Error Reporting

Medical liability system + litigious society: potential barriers to systematic efforts to uncover, learn from mistakes

Patient Safety Improvement Act (2002)

Patient Safety and Quality Improvement Act of 2005

Proposed federal legislation to protect voluntary reporting of ordinary injuries, “near misses”

Leapfrog Group

Need for implementation of evidence-based standards such as

Computerized physician (or prescriber) order entry (CPOE)

Leapfrog developed evaluation tool

Evidence-based hospital referral (EHR)

Intensive-care-unit physician staffing (IPS)

Question #3

Is the following statement true or false?

A sigma value of three indicates lower performance than a sigma value of five.

Answer to Question #3

True

A sigma value is a statistical measurement that reflects performance. Thus, the higher the sigma value, the better the performance.

Bar Coding Medications

Reduction in point-of-care medication errors

National drug code number for all prescription, OTC meds used in hospitals

Bar coding + CPOE = increased ability to follow “five rights” of medication admin

Changing Organizational Culture

Quality and Safety Education for Nurses (QSEN) project

Knowledge, skills, and attitudes (KSA) necessary to continuously improve the quality and safety of the health care system

KSA—better able to identify potential errors and intervene before errors occur

Organizational cultures needing to remove blame from individual and focus on how organization can be modified to reduce likelihood of errors

“Just culture” or “culture of safety management”

Patient Safety Solutions

WHO’s Word Alliance for Patient Safety and the Collaborating Centre packaged nine effective solutions called patient safety solutions to reduce health care errors

WHO (2017) initiated its third Global Patient Safety Challenge: Medication Without Harm

See Box 14.6

Question #4

Which of the following would most likely be most significant in promoting a culture of safety management?

A. Mandatory reporting of errors

B. Six Sigma approach

C. Bar coding meds

D. Removal of blame

Answer to Question #4

Although mandatory reporting of errors, a Six Sigma approach, and bar coding meds are important in promoting a culture of safety management, perhaps the most significant change that must occur is that organizational cultures must be created that remove blame from the individual and focus on how the organization can be modified to reduce the likelihood of errors occurring in the future.

End of Presentation

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4 Medical Errors: An Ongoing Threat to Quality Health Care

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