1. Medical Errors in the Hospital Amit Chatterjee, MD The Ohio State University July 21, 2009

2. Medical Errors in the Hospital General Outline Background Statistics Strategies Implementation and Transformation Other Resources References Questions

3. Medical Errors in the Hospital What is Quality Healthcare? The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge

4. Medical Errors in the Hospital Who cares? The Institute of Medicine (IOM) launched effort on assessing and improving the nation’s quality of care in 1996. In 1999, the extremely important book, To Err is Human: Building a Safer Health System, was released. A follow up book/report was released in 2001, Crossing the Quality Chasm: A New Health System for the 21st Century. The Agency for Healthcare Research and Quality also focuses on Medical Errors and Patient Safety, division of the US Dept of Health and Human Services. The US FDA (Food and Drug Administration) has the MedWatch program for reporting medication errors.

5. Medical Errors in the Hospital Statistics Estimated 44,000 to 98,000 deaths occur in the United States each year due to medical errors. Over 770,000 patients injured due to medical errors. Medication errors occur in nearly 1 of every 5 doses given to patients in typical hospital. Reported rates of adverse drug events range 2.4 to 6.1 per 100 admissions or discharges. Estimated to be eighth leading cause of death in the United States.

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7. Medical Administration Errors 1.Account for 38% of Medication Errors 2.Only 2% of administration errors are intercepted 3.Safety at point of care is greatest area for potential improvement IV Medication Errors 1.54% of potential ADE associated with IV medications 2.ADE’s occurred between 2.9 to 3.7 percent of hospitalizations 3.61% of serious and life-threatening errors associated with IV medications 4.56% of medications errors associated with IV medications. Medication Error Costs 1.Cost is $4685 (1993) per preventable Adverse Drug Event (ADE) 2.Annual cost of medication error is $2.8 million for 700-bed teaching hospital 3.Estimated annual national cost of preventable ADE is $2 billion.

8. Medical Errors in the Hospital Strategies 1.Enhancing IT (Information Technology) within the healthcare system. 2.Changing working conditions and design 3.Enhance communication and teamwork. 4.Have proper oversight and checks to ensure proper healthcare delivery is taking place on a regular basis. 5.Encourage pharmacy intervention. 6.Allow ways to ease the use of safety reporting.

9. Medical Errors in the Hospital Enhancing IT (Information Technology) 1.Electronic Health Record Health information and data Result management Order management Decision support Electronic communication and connectivity Patient support Administrative processes and reporting Report and population health 2.Electronic Bar Codes for patients as well as medications for matching medications and the patients that they are given to. 3.Giving patients access to educational materials about diseases and medications given for these diseases.

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11. Changing Work Conditions and Design 1.Resident Duty Hours IOM recommended and ACGME enforced Night float systems 80 hour work week restrictions, 30 hour shift length Minimum 10 hours off in between shifts 2.Frequent Changes in Nursing Staff 3.Channeling High-Risk Technical Procedures to High-Volume Physicians 4.Avoidance of Distractions in the Healthcare Workplace 5.Processes to Improve Information Exchange Between Hospital and Non- Hospital Settings. Eresults Radweb Epic WebESA

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13. Enhance Communication and Teamwork 1.Patient Safety Culture surveys – ONEVoice survey

14. Medical Errors in the Hospital Enhance Communication and Teamwork 1.Encourage Team Rounding (Residents, Interns, Medical Students, PCRM, Attending). 2.Electronic Medical Record and Ease of Accessibility. 3.Timely and Accurate Handoff Notes on Daily Basis. 4.Implementing and Enforcing Core Measures for Common Illnesses –Congestive Heart Failure –Pneumonia –Diabetes –DVT Prevention 5.Medication Reconciliation 6.Time Out Procedure Forms

15. Medical Errors in the Hospital Proper Oversight and Checks 1.Accreditation Programs (e.g. Magnet Recognition for Nursing) 2.JCAHO – Joint Commisions Accreditation for Hospitals 3.ACGME – Accreditation for Residency and Graduate Medical Education 4.US Government – FDA (Food and Drug Administration), Medicare and Medicaid Programs 5.Institution itself – OSU Administration 6.Physicians 7.Nurses 8.Pharmacists 9.Even Residents and Medical Students!

16. Medical Errors in the Hospital Encourage Pharmacy Intervention 1.Barcodes for patients and matching them for medication administration purposes. 2.Having pharmacists oversee medication orders written for patients. 3.Have built-in programs within the EMR to allow for checking of certain medication dosages (e.g. coumadin, lovenox). 4.Have pharmacists round with primary team to assist with day-to-day management of medications and proper dosages. 5.Implement an ED pharmacist to ensure medications are being given properly to patients and that they are being discharged safely as well. Adds layers of redundancy to help prevent medication errors.

17. Medical Errors in the Hospital Safety Reporting 1.Needs to be available for both patients and staff 2.Discharge paperwork should help direct patients for follow up and where to go for questions. 3.Patient Safety Organizations allow for data collection and analysis for the identification and reductions of risks and hazards associated with patient care. Ohio Patient Safety Institute is a component entity of Ohio Health Council PSO Number: P0041 Street Address: 155 East Broad Street, Floor 15 City, State, Zip Code: Columbus, OH 43215 Telephone: (614) 221-7614 Fax: (614) 221-4771 E-Mail: rosaliew@ohanet.org Web Site: www.ohiopatientsafety.org Effective Date & Time of Listing: 2/11/2009 12:01 AM ET Two Contract Certification Due by 2/11/2011: Information Not Received Disclosures & Findings: None

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19. Other Resources To Err is Human: Building a Safer Health System: http://books.nap.edu/openbook.php?isbn=0309068371 http://books.nap.edu/openbook.php?isbn=0309068371 20 Tips to Prevent Medical Errors: http://www.ahrq.gov/consumer/20tips.htm 30 Safe Practices for Better Health Care: http://www.ahrq.gov/qual/30safe.htm Crossing the Quality Chasm: A New Health System for the 21st Century: http://www.iom.edu/?id=12736 http://www.iom.edu/?id=12736 Key Capabilities of an Electronic Health Record System: http://www.iom.edu/?id=19374 http://www.iom.edu/?id=19374

20. Medical Errors in the Hospital References  The Institute of Medicine: IOM Health Care Quality Initiative http://www.iom.edu/?id=35957 http://www.iom.edu/?id=35957  Agency for Healthcare Research and Quality: Medical Errors and Patient Safety http://www.ahrq.gov/qual/errorsix.htm http://www.ahrq.gov/qual/errorsix.htm  US Food and Drug Administration: Strategies to Reduce Medication Errors http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm143553.htm http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm143553.htm  Cardinal Health Quality Statistics http://www.cardinal.com/clinicalcenter/education/statistics/index.asp http://www.cardinal.com/clinicalcenter/education/statistics/index.asp  National Vital Statistics Report, Final Data for 2006 http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf  The Institute of Medicine: Resident Duty Hours http://www.iom.edu/CMS/3809/48553/60449/60471.aspx http://www.iom.edu/CMS/3809/48553/60449/60471.aspx  The Ohio State University Medical Center https://www.osumc.edu

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