Exploring strategies for reducing hospital errors

The purpose of this study is to explore current strategies for reducing errors at U.S. hospitals. Reports by the Institute of Medicine highlight concerns about the staggering number of medical errors that occur in the U.S. healthcare system. These reports have exerted considerable pressure on hospitals to establish programs that reduce errors and improve patient safety. A previous research study identifies seven critical strategies for reducing hospital errors based on a case study of four Chicago-area hospitals. These strategies include (1) partnership with stakeholders, (2) reporting errors free of blame, (3) open discussion of errors, (4) cultural shift, (5) education and training, (6) statistical analysis of data, and (7) system redesign. This article reports the results of our nationwide survey of 525 hospitals. We examined the perceptions of healthcare quality directors about the importance of these seven patient safety strategies, the factors that act as barriers, the level of adoption of these strategies, and the benefits resulting from implementation of these strategies. Our results indicate that a considerable gap exists between current hospital practices and the perceived importance of various approaches to improving patient safety. Results of our regression analysis reveal that internal organizational barriers are associated with a larger gap between perceived importance and actual implementation. Moreover, the regression analysis also reveals that smaller gaps are associated with better error outcomes such as reduction in the frequency and severity of errors. The findings provide specific directions for enhancing patient safety programs at hospitals in the future.     

Confidentiality, privacy, and restrictions for computer-based patient records

The public wants four things from our healthcare system: quality, affordability, security, and access (Taylor 1993). To improve quality and affordability of, and access to, healthcare, we turn to information technology for support. With the increased use of information technology in healthcare, concerns associated with the security of patient records are also increasing. Personal privacy and information technology are on a collision courses with respect to the privacy and confidentiality of computer-based patient medical records.     

Building confidence into communication of bad news: The role of the patient advocate

The need for a patient advocate is greater than ever as medical errors continue to occur. News media quickly capture the egregious errors, but more errors are experienced by patients who suffer quietly. These patients know something wrong occurred during their hospitalization, but they choose to refrain from pursuing litigation against the providers. There also are thousands of individuals who never realize that a medical error occurred. In a patient‐ and family‐centered care environment, patient advocates can bridge these issues by participating on the healthcare team that is involved with the initial disclosure of the event and by providing a caring relationship to assure the patient's voice is heard and understood.     

Tuberculosis control in Alberta. A federal,provincial and regional public health partnership

The number of cases of tuberculosis in Alberta or Canada may not be large, but the public health and medical costs of just a few cases can be prohibitive. For example, the costs of managing cases of multidrug-resistant tuberculosis and their contacts, can exceed the entire annual budget of a program. This was evident in New York City in the late 1980s and early 1990s, when $1 billion in public funds were spent reversing a major resurgence of drug-resistant and susceptible tuberculosis. In Canada, the Walkerton Inquiry has identified an apparent failure of provincial public policy to adequately address public health needs. This has resulted in decreased public confidence and potential liabilities for the policy-makers. In the design of the Tuberculosis Control Program of Alberta, the notion of a quasicentralized or quasidecentralized program is rejected. Rather there is an appeal to the notion of a partnership of responsibility that recognizes jurisdictional and non-jurisdictional public health, case management and epidemiologic realities, the integral contribution of each level of government and the need to be accountable to the public's health and purse. For levels of government not to properly discharge their responsibilities may be perceived as an abrogation of the public trust and a disregard of the Tuberculosis Control Policy Package and operational directives of the World Health Organization.     

Adoption of information technology in primary care physician offices in Alberta and Denmark, Part 1: Historical, technical and cultural forces

Denmark and Alberta are both advanced in the application of the Western scientific model of healthcare and both currently enjoy similar levels of economic prosperity. This article evaluates the current state, driving forces and general health system factors that have impacted two culturally and historically different medical jurisdictions--Denmark and Alberta, Canada.     

The successful application of business coaching to decrease preventable medical errors

The number and cost of preventable medical injuries and deaths continue to rise in the U.S. healthcare system despite many attempts to avert such occurrences. The Centers for Medicare & Medicaid Services has prudently decided to deny claims for the healthcare costs incurred in treating certain preventable injuries. With the passage of a the Patient Protection and Affordable Care Act, the list of denied healthcare procedures to correct preventable medical injuries will grow, resulting in a further squeezing of the profit margins of medical institutions and providers. In this article, we show that business coaching of the healthcare team is successful in reversing the alarming growth rate of medical errors, thus ensuring the financial success of healthcare institutions adopting business coaching practices.     

Eliminating US hospital medical errors

PURPOSE: Healthcare costs in the USA have continued to rise steadily since the 1980s. Medical errors are one of the major causes of deaths and injuries of thousands of patients every year, contributing to soaring healthcare costs. The purpose of this study is to examine what has been done to deal with the medical-error problem in the last two decades and present a closed-loop mistake-proof operation system for surgery processes that would likely eliminate preventable medical errors. DESIGN/METHODOLOGY/APPROACH: The design method used is a combination of creating a service blueprint, implementing the six sigma DMAIC cycle, developing cause-and-effect diagrams as well as devising poka-yokes in order to develop a robust surgery operation process for a typical US hospital. FINDINGS: In the improve phase of the six sigma DMAIC cycle, a number of poka-yoke techniques are introduced to prevent typical medical errors (identified through cause-and-effect diagrams) that may occur in surgery operation processes in US hospitals. It is the authors' assertion that implementing the new service blueprint along with the poka-yokes, will likely result in the current medical error rate to significantly improve to the six-sigma level. Additionally, designing as many redundancies as possible in the delivery of care will help reduce medical errors. PRACTICAL IMPLICATIONS: Primary healthcare providers should strongly consider investing in adequate doctor and nurse staffing, and improving their education related to the quality of service delivery to minimize clinical errors. This will lead to an increase in higher fixed costs, especially in the shorter time frame. ORIGINALITY/VALUE: This paper focuses additional attention needed to make a sound technical and business case for implementing six sigma tools to eliminate medical errors that will enable hospital managers to increase their hospital's profitability in the long run and also ensure patient safety.     

Career Success and Life Satisfaction for Female and Male Healthcare Managers

Medical errors cause up to 98,000 people to die annually in the United States. They are the fifth leading cause of death and cost the United States $29 billion annually (Kohn 1999). Medical errors fall into 4 main categories: diagnostic, treatment, preventative, and other. A review of literature reveals several proposed solutions to the medical error problem. One solution is to change the system for reporting medical errors. This would allow for the tracking of errors and provide information on potential problematic areas. A National Center for Patient Safety is proposed, which would set national goals towards medical errors. Another solution is the setting of performance standards among individual entities of healthcare delivery, such as hospitals and clinics. Another solution involves implementing a culture of safety among healthcare organizations. This would put the responsibility of safety on everyone in the organization. A change in education is yet another proposed solution. Informing medical students about errors and how to deal with them will help future physicians prevent such errors. The final solution involves improvements in information technology. These improvements will help track errors, but also will prevent errors. A combination of these solutions will change the focus of the healthcare industry toward safety and will eventually lead to billions in savings, but more importantly, the saving of lives.     

Preventing errors in healthcare: a call for action

Medical errors cause up to 98,000 people to die annually in the United States. They are the fifth leading cause of death and cost the United States dollar 29 billion annually (Kohn 1999). Medical errors fall into 4 main categories: diagnostic, treatment, preventative, and other. A review of literature reveals several proposed solutions to the medical error problem. One solution is to change the system for reporting medical errors. This would allow for the tracking of errors and provide information on potential problematic areas. A National Center for Patient Safety is proposed, which would set national goals towards medical errors. Another solution is the setting of performance standards among individual entities of healthcare delivery, such as hospitals and clinics. Another solution involves implementing a culture of safety among healthcare organizations. This would put the responsibility of safety on everyone in the organization. A change in education is yet another proposed solution. Informing medical students about errors and how to deal with them will help future physicians prevent such errors. The final solution involves improvements in information technology. These improvements will help track errors, but also will prevent errors. A combination of these solutions will change the focus of the healthcare industry toward safety and will eventually lead to billions in savings, but more importantly, the saving of lives.     

Changes in intern attitudes toward medical error and disclosure

Medical Education 2012: 46: 668–677 Context The 2000 Institute of Medicine report, ‘To Err is Human: Building a Safer Health System’, focused the medical community on medical error. This focus led to educational initiatives and legislation designed to minimise errors and increase their disclosure. Objectives This study aimed to investigate whether increased general awareness about medical error has affected interns’ attitudes toward medical error and disclosure by comparing responses to surveys of interns carried out at either end of the last decade. Methods Two cohorts of interns for the academic years 1999, 2000 and 2001 (n = 304) and 2008 and 2009 (n = 206) at a university hospital were presented with two hypothetical scenarios involving errors that resulted in, respectively, no permanent harm and an adverse outcome. The interns were questioned regarding their likely responses to error and disclosure. Results We collected 510 surveys (100% response rate). For both scenarios, the percentage of interns who would be willing to fully disclose their mistakes increased substantially from 1999–2001 to 2008–2009 (‘no permanent harm’: 38% and 71%, respectively [p < 0.001]; ‘adverse outcome’: 29% and 55%, respectively [p < 0.001]). About two thirds of fully disclosing interns in both scenarios believed ‘the patient’s right to full information’ to be the primary reason for their disclosure. Fear of litigation in response to error disclosure decreased (70% and 52%, respectively), the percentage of interns who felt that ‘medical mistakes are preventable if doctors know enough’ decreased (49% and 31%, respectively), belief that competent doctors keep emotions and uncertainties to themselves decreased (51% and 14%, respectively), and agreement with leaving medicine if one (as an intern) caused harm or death decreased (50% and 3%, respectively). Prior training about medical mistakes increased more than four‐fold between the cohorts. Conclusions This comparison of intern responses to a survey administered at either end of the last decade reveals that there may have been some important changes in interns’ intended disclosure practices and attitudes toward medical error.     

Systematic review of the perceptions and experiences of accessing health services by adult victims of domestic violence

This systematic review synthesizes evidence on the perceptions and experiences of adult victims of domestic violence when accessing healthcare services. The review was concerned with disclosure of domestic violence by adult victims when accessing health services, the responses of healthcare professionals to these victims, victims' perceived barriers to support, and the appropriateness of support and referrals. These aims required the review to focus on studies using in-depth qualitative methods to explore victims' perceptions and experiences. A comprehensive systematic search of 12 databases was carried out in June/July 2005. Application of the review protocol and inclusion criteria resulted in 10 studies (conducted in the UK, USA and Australia) being considered eligible for the review. Data were extracted from these studies and a quality assessment completed. Thematic analysis was carried out to enable the identification of recurrent themes within the included studies. Findings indicate that victims of domestic violence experience difficulties when accessing healthcare services. Victims perceive that these difficulties can be attributed to inappropriate responses by healthcare professionals, discomfort with the healthcare environment, perceived barriers to disclosing domestic violence, and a lack of confidence in the outcomes of disclosure to a health professional. The methodological quality of included studies was variable, but no papers were rejected based on quality issues. These results can contribute to and inform a comprehensive assessment of the experiences of adult victims of domestic violence when accessing healthcare services. The health service is in a unique position to contribute towards the assessment and identification of domestic violence and to provide access to appropriate support. The messages of this study are important for policy-makers and practitioners.     

National Burden of Preventable Adverse Drug Events Associated with Inpatient Injectable Medications: Healthcare and Medical Professional Liability Costs

Background

Harmful medication errors, or preventable adverse drug events (ADEs), are a prominent quality and cost issue in healthcare. Injectable medications are important therapeutic agents, but they are associated with a greater potential for serious harm than oral medications. The national burden of preventable ADEs associated with inpatient injectable medications and the associated medical professional liability (MPL) costs have not been previously described in the literature.

Objective

To quantify the economic burden of preventable ADEs related to inpatient injectable medications in the United States.

Methods

Medical error data (MedMarx 2009–2011) were utilized to derive the distribution of errors by injectable medication types. Hospital data (Premier 2010–2011) identified the numbers and the types of injections per hospitalization. US payer claims (2009–2010 MarketScan Commercial and Medicare 5% Sample) were used to calculate the incremental cost of ADEs by payer and by diagnosis-related group (DRG). The incremental cost of ADEs was defined as inclusive of the time of inpatient admission and the following 4 months. Actuarial calculations, assumptions based on published literature, and DRG proportions from 17 state discharge databases were used to derive the probability of preventable ADEs per hospitalization and their annual costs. MPL costs were assessed from state- and national-level industry reports, premium rates, and from closed claims databases between 1990 and 2011. The 2010 American Hospital Association database was used for hospital-level statistics. All costs were adjusted to 2013 dollars.

Results

Based on this medication-level analysis of reported harmful errors and the frequency of inpatient administrations with actuarial projections, we estimate that preventable ADEs associated with injectable medications impact 1.2 million hospitalizations annually. Using a matched cohort analysis of healthcare claims as a basis for evaluating incremental costs, we estimate that inpatient preventable ADEs associated with injectable medications increase the annual US payer costs by $2.7 billion to $5.1 billion, averaging $600,000 in extra costs per hospital. Across categories of injectable drugs, insulin had the highest risk per administration for a preventable ADE, although errors in the higher-volume categories of anti-infective, narcotic/analgesic, anticoagulant/thrombolytic and anxiolytic/sedative injectable medications harmed more patients. Our analysis of liability claims estimates that MPL associated with injectable medications totals $300 million to $610 million annually, with an average cost of $72,000 per US hospital.

Conclusion

The incremental healthcare and MPL costs of preventable ADEs resulting from inpatient injectable medications are substantial. The data in this study strongly support the clinical and business cases of investing in efforts to prevent errors related to injectable medications.Preventable medication errors have emerged as a prominent cost and quality issue in the United States, and are estimated to impact more than 7 million patients, contribute to 7000 deaths, and cost almost $21 billion in direct medical costs across all care settings annually.1,2 Adverse drug events (ADEs) are harms that result from medication use; when these harms result from a medication error, they are known as “preventable ADEs.”3 The inpatient hospital setting is particularly resource-intensive in terms of care delivered and exposure to potential harms and errors.4,5 In 2007, the Institute of Medicine (IOM) estimated that 1 medication error occurred per patient per day in hospital care.4 In 2008, the US Department of Health and Human Services (HHS) estimated that approximately 1 of every 7 (13.5%) hospitalized Medicare patients experienced permanent harm from a medical error, and that 37% of these inpatient injuries were associated with medications.5 In addition, the study investigators estimated that 50% of these ADEs were preventable.5The majority of hospitalized patients receive medications, which means that a high volume of doses are prescribed and are administered daily in the inpatient setting. A study in a 735-bed academic medical center estimated that approximately 16,000 medication doses were administered daily.6 This study and others report that up to 1 of 5 medication doses are associated with an error, and that between 3% and 7% of these errors are potentially harmful to patients.6,7Furthermore, many of the medications used in the inpatient setting are delivered by injectable routes; these injectable medications have among the highest risk for error and the most severe harms.8 In a study of inpatient ADEs, including life-threatening ADEs, 50% of the medications that were implicated were injectable, including antihypertensives, insulin, and anticoagulants.9 Similarly, studies in the inpatient intensive care unit setting, where medications delivered by infusion are common, have reported that a patient''s risk for a medication error is approximately 10%, with 1 in 100 errors causing harm that requires life-saving treatment.8,10In addition to the clinical harms caused by preventable ADEs, healthcare stakeholders incur the economic consequences as well. When a patient experiences a preventable ADE, there may be direct medical costs to payers, such as an extended inpatient stay, use of additional medications, and physician visits in an outpatient setting to restore the patient''s health. There are also indirect costs, which may include missed work, reduced quality of life, and disability for the patient, as well as possible uncompensated expenses for the healthcare provider. In a 1997 study, preventable ADEs were estimated to add $4685 in adjusted, postevent costs to an inpatient hospitalization, amounting to an additional $2.8 million in annual costs per hospital.11 Citing articles by Bates and colleagues and Classen and colleagues, the IOM estimates that preventable ADEs affect up to 450,000 hospitalized patients and add $3.5 billion in extra costs to hospitals annually.4,11,12

KEY POINTS

• ▸ Half of all adverse drug events (ADEs) are a result of medication errors and are therefore preventable.
• ▸ Injectable medications are among those at highest risk for error and can be associated with life-threatening events.
• ▸ This is the first analysis of the national burden of medication errors associated with inpatient injectable medications.
• ▸ The results show that preventable ADEs associated with injectable medications impact more than 1 million patients in the inpatient setting.
• ▸ Injectable-related preventable ADEs cause an increase of $2.7 billion to $5.1 billion in annual costs to US healthcare payers, with an average of $600,000 in extra annual cost per hospital.
• ▸ Furthermore, the analysis of liability claims shows a cost burden of $300 million to $610 million annually in medical professional liability, with an average cost of $72,000 per hospital.
• ▸ Reducing injectable medication errors and the associated preventable ADEs can improve quality of care for patients and reduce unnecessary cost for payers, hospitals, and physicians.
• ▸ The study''s broad approach to costs, including the 4 months after discharge and medical professional liability costs, is aligned with healthcare reform initiatives in the United States, where payers are introducing new payment structures that consider patient outcomes beyond the inpatient stay.

Lawsuits and administrative actions related to preventable ADEs also increase costs for healthcare stakeholders. Provider costs related to medical professional liability (MPL), once called “medical malpractice,” are substantial. A previous study of MPL claims estimated that 73% of ADE-related cases were preventable; although legal defense costs were similar for inpatient and outpatient ADEs, the legal settlement costs were greatest for inpatient ADEs, which averaged $376,500 per MPL case.13We conducted a comprehensive analysis of US payer and MPL costs for preventable ADEs related to injectable medications in the inpatient setting. We chose to focus this study on preventable ADEs resulting from injectable medications for several reasons, including their frequent use, their high risk for error, and their potential for targeted prevention strategies in the inpatient setting.14     

Improvements in the safety of patient care can help end the medical malpractice crisis in the United States

The publication of To Err is Human: Building a Safer Health System by the Institute of Medicine (IOM) in 1999 made the general public aware of the large number of patients that suffer preventable medical injuries in hospitals throughout the United States. Improvements in patient safety are needed to reduce this high incidence of medical error and must include the establishment of a culture of safety in every healthcare facility. A culture of safety is characterized by honesty, transparent error communication, and a systems analysis approach to medical error prevention. This type of medical culture can serve as the foundation for sustained improvements in patient safety and will help provide permanent relief from the medical malpractice crisis. Health policymakers should create policies that encourage hospital executives to establish and maintain cultures of safety in their institutions.     

Learning not to take it seriously: junior doctors' accounts of error

Objectives We aimed to investigate experiences of, and responses to, medical error amongst junior doctors and to examine the challenges junior doctors face and the support they receive. Methods We carried out a qualitative study of 38 randomly selected pre‐registration house officers (PRHOs) in 10 hospitals. All 38 had graduated in 2000 or 2001 from a single medical school. Results Errors were common and sometimes serious. In relation to disclosure and learning from error, four main themes emerged: a norm of selective disclosure; the effects of the team; individualised blame and responsibility, and the ‘learning moment’. Trainees reported disclosing errors informally, particularly when teams were seen as supportive, but were reluctant to criticise colleagues. Formal reports and disclosure to patients were very rare. Patient care was compromised when juniors did not access senior help, often when working outside their usual team environment. Lack of cooperation between teams and poor continuity of care also contributed to errors. Learning was maximised when errors were formally discussed and constructive feedback offered. However, both blame and the prioritisation of reassurance over learning and structured feedback appeared to inhibit reflection on the experience of error. Conclusions Junior doctors need help to reflect on their experiences and to recognise where they may have made mistakes, particularly in the contexts of shift‐work and fragmented teams. Formal reporting systems alone will not facilitate learning from error. Juniors require individual clinical supervision from seniors with appropriate training. Such expertise may benefit the whole team and the training environment.     

Devolving Healthcare Delivery to Regional Health Authorities: Is Health Technology Assessment Prepared to Follow?

Since the establishment of health technology assessment units in the latter 1980s, Canada has witnessed an unprecedented transformation of the governance, management and service delivery of its healthcare system. In Alberta, this transformation culminated in the establishment of regional health authorities that provide integrated healthcare to Albertans. With the shift of responsibility for healthcare delivery from the provincial to the regional level, the Alberta Heritage Foundation for Medical Research HTA unit recognized that for health technology assessment to continue to be relevant, it must follow this change. Four steps were taken to refocus the unit's scope: a thorough analysis of the healthcare environment; face-to-face interviews with the chief executive officers of the regions; the development of a framework for HTA in the regions; and the organization of a conference on evidence-based decision making. These steps were helpful in bringing HTA to the attention of regional decision makers. A formal, analytical assessment of the regional healthcare environment, provision of general information (through the framework and conference) and individual information (through face-to-face interviews) enabled a proactive engagement with regions. However, to meet the demands and needs of a population that expects comprehensive coverage that delivers “state of the art” diagnostics and treatments, the efficacy and effectiveness of interventions can sometimes be of subordinate importance.     

The healthcare system in HIV/AIDS: an inextricable component in the experience of family care

Through a phenomenological study following van Manen's approach, family care experiences of caregivers and care receivers in the context of HIV/AIDS were studied in Mumbai, India. Data gathered through conversational interviews were analysed using the holistic and highlighting approaches. Interactions with the formal healthcare system contributed to the essential meaning of participants’ experiences even though the context of care was primarily familial. These interactions included instances of violations of testing and confidentiality guidelines and refusals to provide treatment in the private and some public health centres, and the provision of instrumental and affective support by the voluntary sector. The poor quality of care at public sector hospitals serving HIV-positive individuals was also described. The paper makes recommendations for improving the interventions of the healthcare system since experiences here are linked to the overall subjective experience of caregiving and care receiving.     

Towards patient-centered health services in India--a scale to measure patient perceptions of quality.

OBJECTIVE: . (i) To develop a reliable and valid scale to measure in-patient and outpatient perceptions of quality in India and (ii) to identify aspects of perceived quality which have large effects on patient satisfaction. DESIGN: Cross-sectional survey of health facilities and patients at clinics. SETTING: Primary health centers, community health centers, district hospitals, and female district hospitals in the state of Uttar Pradesh in north India. MAIN OUTCOME MEASURES: Internal consistency, validity, and factor structure of the scale are evaluated. The association between patient satisfaction and perceived quality dimensions is examined. RESULTS: A 16-item scale having good reliability and validity is developed. Five dimensions of perceived quality are identified-medicine availability, medical information, staff behavior, doctor behavior, and hospital infrastructure. Patient perceptions of quality at public health facilities are slightly better than neutral. Multivariate regression analysis results indicate that for outpatients, doctor behavior has the largest effect on general patient satisfaction followed by medicine availability, hospital infrastructure, staff behavior, and medical information. For in-patients, staff behavior has the largest effect followed by doctor behavior, medicine availability, medical information, and hospital infrastructure. CONCLUSIONS: The scale developed can be used to measure perceived quality at a range of facility types for outpatients and in-patients. Perceived quality at public facilities is only marginally favorable, leaving much scope for improvement. Better staff and physician interpersonal skills, facility infrastructure, and availability of drugs have the largest effect in improving patient satisfaction at public health facilities.