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Medical error is clearly the Number One problem in healthcare, contributing to more deaths in the USA than motor vehicle accidents, falls, drowning and plane crashes combined—see Figure 1 below. Most medical errors are related to system problems, not individual negligence or misconduct, and are preventable (see our other Summary Statistic on the preventability of adverse events). Zegers M, Bruijne MC de, Wagner C, Hoonhout LHF, Waaijman R, Smits M, Hout FAG, Zwaan L, Christiaans-Dingelhoff I, Timmermans DRM, Groenewegen PP, Wal G van der. To learn about the 5 things you get when you hire Alan Sackrin, click on the "About" link above.
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In 2000, a deeper look into medical errors considered deaths caused by “normal complications”. When preventable complications are counted as errors, the number of deaths increases to 200,000 per year in the U.S.
If we muddy statistics, it is interesting to compare crab fishing to be­ing in the hospital.
You can decide if you want to fish on a crab boat, but you may have little choice about going to the hospital. Vision and MissionVision: A world where health consumers seek real value in healthcare and are engaged in efforts to improve the safety of their care.
Mission: To provide health consumers with high-quality publications to meet their healthcare goals in a safe and effective manner. Correspondence Address:Heenopama ThakurDepartment of Pharmacology, Vir Chandra Singh Garhwali Govt. According to the Institute of Medicine report, titled “To Err Is Human: Building a Safer Health System”, it was first reported in 1999 that between 44,000 and 98,000 Americans die in hospitals each year due to mistakes in their care. When it comes to preventing medication errors, hospitals everywhere face a major dilemma: Everyone agrees that reporting problems is the first step to preventing others from happening, but few clinicians put that belief into practice and submit error reports when something goes wrong. The situation was no different at Delnor-Community Hospital, a 128-bed facility in Geneva, Ill., that in 2004 was searching for ways to prevent medication problems within its walls. The hospital did away with having physicians sign drug error forms, but it decided against anonymous reporting.
A vast body of literature points out that nurses and pharmacists are simply too worried that they’ll be punished or humiliated if they admit to making mistakes.
To do that, the hospital employed a variety of techniques, from educating nurses, pharmacists and physicians alike about the importance of reporting errors to developing a medication event team to coordinate a hospital-wide quality improvement effort. It may seem trivial, but the hospital found that simply changing the name and tone of its error reporting form went a long way to encouraging staff to participate in the reporting program. The hospital took what it called a medication error report— which sounded punitive, staff said in surveys—and replaced it with two forms that had kinder, gentler names: a medication event form and a near-miss form. The hospital made sure that both forms were brief and concise; the near-miss form is only a half page, while the medication event form is one page.
The new forms stuck to the basics, asking nurses and pharmacists to describe what happened and how it could have been avoided.
As it reinvented its error-reporting process, Delnor-Community grappled with another issue: Who should sign the forms?
The hospital had always required nurses or pharmacists to have a physician sign drug error forms before submitting them. But when it came to another decision on signatures—whether to allow staff to anonymously submit reports—the hospital decided to hold the line.
Because both were prescribed high-risk medications that have similar names—Cytotec and Cytoxan—the nurse almost gave one patient the wrong medication.
The involvement of the medication event team also ensures that process changes are made across the entire system, not just on the floor where an error takes place. Today, because that nurse will theoretically report the problem using a medication event form, Ms.
When the hospital compared the annual number of medication error reports it received before and after making these changes, the results were dramatic.
Creating a short near-miss form was key to encouraging staff to submit reports, but the medication event team found that it also made nurses and pharmacists more willing to use the longer medication report form. The hospital also continues to refine its reporting forms to collect more useful information.
Because clinical staff were sometimes puzzled about exactly what constitute contributing factors, checkboxes have now been added listing some of the staff’s most common perceptions of contributing causes to medication errors.


Those checkboxes not only make completing the form faster and easier for nurses and pharmacists, but they allow the medication event team to analyze the causes and effects of medication events.
In 2005, the hospital took another step forward when it added a bedside medication verification system, which helps ensure that medications are being given to the right patients by comparing the barcode on the medicine and the patient’s wristband. A study published in Health Affairs examined the records of 795 patients at three teaching hospitals. To read the entire article, click on New Study Finds Medical Error Rates are Underreported. For the sake of simplicity, I have summarised the study results to one figure—10% (or one in every ten hospital admissions).
Medical errors cause more accidental deaths in the USA than motor vehicle accidents, falls, drowning and plane crashes combined. The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. The incidence of adverse events in Swedish hospitals: a retrospective medical record review study.
Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study.
At the time, they mentioned this outnumbered motor vehicle accidents (43,458), breast cancer (42,297), and AIDS (16,516). For fans of the Discovery Channel’s Deadliest Catch, the Centers for Disease Control reported 260-310 deaths per year for every 100,000 full-time Alaskan crab workers. A systematic approach of tracking and reporting medication errors at a tertiary care university hospital, Karachi, Pakistan. Reducing medication errors and increasing patient safety: Case studies in clinical pharmacology. Computerized physician order entry in the critical care and general inpatient setting: A narrative review. As humans we are always susceptible to make errors, but understanding why we make them will help us design systems that decrease the chances of such errors to happen. Eg: The nurse is distracted in her busy shift and gives a medication to her patient which was intended for another patient.
The rule based errors or cognitive errors are very interesting and if you wish to learn more then refer to this brief article by Dr.
Latent Errors :   Latent errors are accidents waiting to happen because of defects in the design of the system.
To combat that mindset, Delnor got to work creating a nonpunitive culture in which staff could report medication errors or near misses without fear of reprisal.
But what really transformed medication error reporting at Delnor-Community were changes the hospital made to its culture of safety and to its reporting form. The two new forms replaced the word “error” with “event”—and focused on system problems, not on individual mistakes. According to Mary VanOyen Force, RN, a team leader of nursing research and performance improvement at the hospital who was instrumental in the initiative, the hospital also made sure both forms were easy to use.
And to make the forms easy to find, they were placed in racks mounted on the wall in each nursing station. During staff focus groups, the medication event teams learned that getting a physician’s signature discouraged many staff from reporting medication problems. Staff who submit either a medication event or near-miss report would receive a personalized thank-you note to their home and a $5 gift card to a local bookstore as recognition for taking time to fill out a medication event report. In the past, many reports would languish on supervisors’ desks for weeks, not only making them useless, but discouraging staff from taking time to write up problems.
She caught the mistake before the error was made and filed a near-miss report—and the patients were separated immediately. Several years ago, for example, if a wrong medication was put in the hospital’s drug-dispensing system, a nurse might pick up the phone and call the pharmacy to report the problem, but that message might or might not be relayed to other pharmacists on other floors.
While the hospital had been receiving about 14 reports a month before the initiative, that number jumped to 72 every month afterwards. In June of this year, in fact, the hospital eliminated the near-miss form altogether and now require all reports to be made on the longer, more detailed form. Force wondered if the hospital’s clinical staff would insist that the short form be reinstated, she says she’s received few, if any, complaints. It has added a standardized category index for medication errors that allows quality improvement staff to compare the hospital’s performance to national benchmarks, and the long form has a more detailed follow-up section that asks nurses to identify the contributing causes of medication events. Those factors can include an emergency situation, multiple prescribers and procedures not being followed.
Kruse is a hospital pharmacist, outpatient clinic pharmacist, leader, and professor of pharmacy. The error may be of commission or omission, with potentially negative consequences for the patient, which would have been judged wrongly by skilled and knowledgeable peers at the time it occurred, independent of whether there were any negative consequences.


It was then said that more people die from medical errors each year than from breast cancer or from motor vehicle accidents.
That is why it is now believed that errors are not made by defective people, but by defective systems. Staff were then asked to put completed forms in colorful collection boxes in the medication rooms.
After much discussion, the hospital dropped its requirement that a physician sign the form, a decision Ms. One near-miss report, for example, focused on two female patients with similar last names who were sharing a room.
She will then call the pharmacy and make sure the problem is corrected hospitalwide, in the medication rooms on every floor. By the fall of 2005—one year after onset of the new process—nurses and pharmacists were submitting between 80 and 120 reports a month. The longer forms give quality improvement staff even more details about how errors occur and how they can be prevented in the future. In some instances, for example, nurses have reported that dim lighting makes it difficult to read labels, which leads to errors. Adding misdiagnosis and undocu­mented er­ror­s could raise the death rate to 400,000 per year.
In addition to patient care, he has collaborated with other health professionals on hospital and clinic committees that affect patient safety.
As if these figures were not staggering enough, a study was published recently in the Journal of Patient Safety that estimated the annual number of medical errors in U.S.
Because one day the attending doesn’t have time to go over every detail about patient care and this unsupervised intern prescribes the wrong medication leading to active error. With this medical errors stands as the third leading cause of death after myocardial infarction and cancer. USA has reduced ADRs to 1 in 3 doses.Physician-Patient-Pharmacist relationship is the basis of a good prescription to ensure better compliance. The causes for medication errors can vary from miscommunication between physician, patient, pharmacist and other paramedical staff involved, to improper storage, labeling, packaging, confusion of look-alike sound alike (LASA), lack of information of current trends, protocols, dosing, references, medicine formularies or unawareness of the staff regarding new medicines, narcotics or high-alert medications. The retrospective arms of the study involved evaluation of 500 written prescriptions for medication errors in-patient tickets of the indoor patient departments (IPD) of surgery, medicine, gynecology, pediatrics, and Ear, Nose and throat (ENT) during previous 5months,whereas, the prospective arm studied 100 outdoor patients (OPD) from department of medicine for the medication errors in prescriptions and compliance. Corrective measures need to be introduced to improve the drug delivery system and retard the incidence of medication errors. For scrutinizing, the steps from prescription to dispensing where the maximum chances of medication error is seen, we need to evaluate the whole process in the Base hospital, Srikot.
Being a hilly region, it is common to find orthopedics and surgical patients besides the medical, obstetrics and gynecological cases in the hospital.The implementation of all the six rights of rational pharmacotherapeutics was examined. Errors such as illegibility, irrational polypharmacy (especially, in geriatric population), absence of isolate report prior to prescription of antimicrobials, absence of sensitivity testing for medicines known to cause serious ADRs, missing pre-operative notes including pre-anesthetic notes, incomplete follow-up instructions, faulty use of abbreviations, use of similar sounding medicine names-LASA however, different effects, especially, in pregnant women, and overwriting in prescriptions were noted. Being a public hospital, prescribing generic medicine is necessary, and the list of available generic medicines is provided to all the physicians in the hospital.
Herein overwriting, LASA, improper labeling and storing have more chances of leading to medication error. There is a multifold increase in population inflow in this region during summer due to pilgrimage season corresponding to the opening of shrines. Additional patient load with same attending staff leads to increased chances of errors in documenting and improper dispensing of medicines. There are more errors of administering wrong concentration and the duration due to the overload, the patients unwillingness to be hospitalized for long and physicians and other paramedical staff trying to provide early and quick medication.On examining the case records, it was found that there were a lot of errors in the implementation of the six rights of rational therapeutics as reported by others too. The MER for OPD was 11% and 22% for IPD, which is nearly 4 and 8 times more respectively than the acceptable rate of errors.
All the medication errors observed by us were leading to administration of wrong doses.Another group established a relation between MER in increasing age of patients with increase in the number of medicines.
The deficiencies need to be identified for bringing in the corrective measures.Remote location, unwillingness to accept newer trends (inherent problems), personal benefit, public ignorance, general belief that injections are better, Standard treatment guidelines (STGs) not available to all the physicians, no regulatory body to keep a check and a general unawareness or negligence in considering medication error as a leading cause of mortality or non-compliance, fear of punishment and negligence by the prescribers and dispensers are limitation in reducing MER. The data so collected can provide feedback to the administration, whose concentrated efforts may help in decreasing the medication errors thereby increasing the therapeutic benefits. Thus disclosing the error also becomes an act of heroism as doctors have high expectations of themselves and find it difficult to acknowledge their errors openly in front of patients, attendants and colleagues.
A need to establish monitoring committee or program with a link to drugs and therapeutic Committee-WHO, where monthly reporting should be mandatory is also recommended.



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