Medical Errors Zheng Yan Advised by: Dr. Dan France

Background (Studies) Two large studies conducted by the Institute of Medicine (IOM) found that adverse events occurred in 2.9 to 3.7% of hospitalizations. “An adverse event is an injury caused by medical management rather than the underlying condition of the patient.” — Institute of Medicine

Background (Studies) In Colorado and Utah hospitals, 8.8% of the adverse events lead to death. The data from the studies suggest that 44,000 - 98, 000 Americans die each year as a result of medical errors.

Background (Cases) 27 year-old patient with leukemia died after erroneous intrathecal administration of vincristine Drug should have been given intravenously 2 year old baby died from a lethal dose of sedative promethazine, instead of anti-convulsant phenobarbital Mix of medications in zipper bag where drugs were kept, because drugs had similar names, and ampoules looked alike

Problem Medical errors average of 1.7 mistakes per patient per day in ICU (out of 200 patient-care activities) Fourth most common cause of death in U.S.

Objective To determine how the amount of workload effects the stress level of the charge nurses in the ER The higher the stress level the higher the probability of committing medical errors. To create solutions that reduce the high workload and thus stress, which in turn reduces the occurrence of a medical errors

Method 180-minute observation periods (Real-time data collection using Palm Pilots) Example of of an observation period. ObservationDate CurrentTask TaskStart TaskStop 9/18/2003 Direct Patient Care 9/18/2000 3:04:09 PM 9/18/2000 3:09:00 PM 9/18/2003 Charting 9/18/2000 3:09:34 PM 9/18/2000 3:10:11 PM 9/18/2003 Getting Old Records 9/18/2000 3:10:16 PM 9/18/2000 3:10:23 PM 9/18/2003 Direct Patient Care 9/18/2000 3:11:03 PM 9/18/2000 3:11:29 PM

Method (Cont.) Categories · Average time to complete tasks (continuous – minutes) Without interruptions With interruptions · Steps traveled (walked) (odometer reading - continuous) · Time in motion (minutes - continuous)

Method (Cont.) · Number of patients managed simultaneously (continuous) · Total number of unique patients managed (continuous) · Number of tasks performed (continuous) · Average direct patient care time (minutes – continuous)

Method (Cont.) Compiled data used to pin point areas where the efficiency could be improve and strategies can be formed to target those areas. Example: 10% patient, 40% paperwork, 10% consults Suggestions: Improved informatics system to streamline the data entry and retrieval process --> more patient care time and less stress from paperwork

Present Work Finishing up Literature Review Preliminary training with palm pilot for observations of charge nurses.

Future Work Data of ER charge nurses collected and analyzed. Creation of strategies for improvement of human communication between nurses and doctors and medical computer systems to reduce level of medical errors .