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Analyzing medical death rate data over an eight-year period, Johns Hopkins patient safety experts have calculated that more than 250,000 deaths per year are due to medical error in the U.S. The Johns Hopkins team says the CDC's way of collecting national health statistics fails to classify medical errors separately on the death certificate.
In their study, the researchers examined four separate studies that analyzed medical death rate data from 2000 to 2008.
According to the CDC, in 2013, 611,105 people died of heart disease, 584,881 died of cancer, and 149,205 died of chronic respiratory disease—the top three causes of death in the U.S. The researchers caution that most medical errors aren't due to inherently bad doctors, and that reporting these errors shouldn't be addressed by punishment or legal action.
The Family Counseling Center for Recovery offers the full continuum of outpatient care from assessment and ambulatory detoxification to ongoing therapy for long-term recovery.
Clients seeking Methadone treatment will be required to present a photo ID and pay $84.00 to cover the first week of Methadone treatment. Please call our office for information regarding the cost of Buprenorphine treatment options. The materials posted on this website are for personal, non-commercial use only and may be downloaded only for personal use.
Family Counseling Center for Recovery offers Intensive Outpatient Programs for Adults, Adolescents and Families in addition to Methadone Detoxification, Assessment and Intervention, Impaired Professionals Program, Hypnosis and Addictions Treatment, Family Group, Heroin Addiction, Alchol Abuse, Chronic Pain and Addictions, Prescription Drug Addiction, Adolescent Substance Abuse, Adolescent Treatment Services, Ambulatory Detoxification, Clonidine Detoxification, Suboxone Detoxification, Naltrexone Medication, Auricular Acupuncture, Daily Medical Attention, Individual, Group and Family Therapy, as well as Financial Assistance available through community resources. Registration clerks and volunteers will be available for patients without health cards or who have difficulty using the technology. Susan Weinkle, MD, discusses the new Live Demonstration session “Soft Tissue Augmentation and Neuromodulators — Simultaneous Cadaver Prosection and Live Patient Injections” presented at 2-5 p.m. Lynda Chin, MD, looks at the possibilities of using computers with artificial intelligence-like capability to help physicians treat cancer patients, which she discussed during the Lila and Murray Gruber Memorial Cancer Research Award and Lectureship Sunday.
Anthony Eugene Oro, MD, PhD, discusses stem cell factors that can help control cancers, as well as be linked to their development, the focus of his Marion B. These reports were analyzed to classify the events by node, related processes, possible causes, and contributing factors and to detect trends and noteworthy cases.
When medication errors arise due to inaccurate or unknown patient weights, the dose of a prescribed medication could be significantly different from what is appropriate.
The researchers are advocating for updated criteria for classifying deaths on death certificates. The newly calculated figure for medical errors puts this cause of death behind cancer but ahead of respiratory disease.
Rather, they say, most errors represent systemic problems, including poorly coordinated care, fragmented insurance networks, the absence or underuse of safety nets, and other protocols, in addition to unwarranted variation in physician practice patterns that lack accountability. More than half of the most commonly abused controlled substances are prescription medications.
While the referring physician will provide treatment for any pain or medical conditions, the FCCR staff can begin an outpatient detoxification program, if indicated. We work closely with inpatient hospitals and treatment centers when inpatient care is indicated.
Mary’s General Hospital are now able to self-register as they arrive for many outpatient appointments by using express kiosks, similar to those found at airports and movie theatres. Mary’s is the first hospital in the Waterloo Wellington Local Health Integration Network to use the self-serve technology for patient registration. Mary’s will improve the patient experience, the accuracy of patient information and the efficiency of the registration process,” says Barbara Guidolin, Vice President, Patient Services and Chief Nursing Executive.
Mostow, MD, talks about evidence-based strategies for reducing medical errors, which will be discussed in “Diagnosis, Treatment, and Prevention of Errors in Dermatology Practice” at 1-3 p.m.
Centers for Disease Control and Prevention's third leading cause of death—respiratory disease, which kills close to 150,000 people per year. The Family Counseling Center has developed a program of cooperation with local physicians to assist in treating this population.
During the detoxification process, clients will learn safe alternative methods to assist them with ongoing symptoms. Use of the kiosks can reduce data entry errors by up to 50 per cent and streamlines the registration process, leading to shorter wait times and improved flow of patients to their appointments. The kiosks also capture pre-visit information, such as symptoms and allergies, and provide visual directions to appointment locations. Anti-infectives, opioids, and anticoagulants were the most common types of medications associated with wrong-patient events. While multiple factors may have contributed to each event, the most common were two patients being prescribed the same medication, improper verification of patient identification, and similar room numbers. Mary’s two kiosks are being used for outpatient appointments for the eye clinic and cataract surgery. Important risk reduction strategies include ensuring proper storage of medications and patient-specific documents, utilizing healthcare technology fully, limiting verbal orders, and improving patient verification throughout the medication-use process.Introduction Patient misidentification has been a long-standing problem that has permeated all aspects of healthcare and led to errors ranging from wrong-site surgeries to discharging infants to the wrong families to ordering incompatible blood.
Breakdowns described in reports most frequently involved failures to obtain accurate patient weight measurements. All fields of the event reports, including harm score and care area, were self-reported, but the medication name fields were adjusted during analysis if information on the medication involved in the error had been available in the event description. Strategies to address these problems include providing all units with the necessary equipment to weigh patients, weighing every patient during triage or admission to facilities, and weighing patients and documenting patient weights only in kilograms. Various trends were quantified using descriptive statistics.Aggregate AnalysisDuring the aforementioned reporting period, the Authority received 826 distinct medication error event reports from Pennsylvania healthcare facilities that were categorized as wrong-patient events.
However, based on the event descriptions, 13 reports (1.6% of total reports) did not actually involve wrong-patient errors and were excluded from the analysis. Both height and weight are needed to use nomograms to determine body surface area and body mass index. The remaining 813 reports represent errors that occurred across the continuum of the medication-use process (from prescribing to administration and monitoring of medications), involved a wide range of medications, and occurred on various patient care units and departments.The errors reported occurred during all nodes of the medication-use process (see Figure). A Look at the NumbersThere is little information in the literature that specifically mentions medication errors that result from missing or inaccurate patient weights. Almost 13% (n = 104) of reports listed anti-infective medications as being involved in the event. Top Five Medication Error Event Types Associated with   Wrong Weights (n=448) Table 2 lists events by the top five units in which the event occurred, representing 54% of all reports. Of the reports involving a known single medication, almost 30% (n = 169) were associated with high-alert medications.
A national survey of EDs shows that more than 50% of all patients admitted to a hospital came through the ED. The third most common care area noted in the reports was the emergency department (9.8%, n = 80). Units Commonly Involved in Medication Errors Involving   Wrong Weights (n=259) A review of the medications commonly reported reveals two key attributes. It is unclear, however, whether the locations noted in the event reports represent where the errors originated or where the errors were discovered.Despite the variety of medication errors involving the wrong patient, few resulted in patient harm. Second, 5 of the top 10 medications involved, representing 236 (49%) of all reports, are high-alert medications.
High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error.6  Table 3. Top 10 Medications Involved in Wrong-Weight Medication   Error Reports (n=304)  Further AnalysisThe second step in the analysis process included a review of each report’s description of the event to determine what specifically went wrong in these reports. Medication procurement consists of a nurse obtaining the wrong medication from various medication storage areas (see Table 1).
For example, multiple reports described a nurse selecting the wrong patient from the automated dispensing cabinet (ADC) screen when retrieving medications. Monitoring is defined as patient assessment activities that occur before or after administration of medications. There are times when patients arriving at hospitals may not be weighed; for example, if a patient is admitted for an emergency, is not ambulant, or is unable to communicate his or her weight.
Medication Storage Areas Involved in Events Occurring  during the Medication Procurement Process, as Reported to the  Pennsylvania Patient Safety Authority, July 2011 to December 2011Many factors, and often more than one factor per event, contributed to patients receiving other patients’ medications during actual medication administration. Most commonly, two patients were prescribed the same medication, and one received the medication dose intended for the other (14.3%, n = 41).
The second most prevalent contributing factor was inadequate identification (ID) check (12.9%, n = 37), in which the event descriptions specifically mention failure to use two patient identifiers and to confirm identity with patient ID bracelets. The study results showed that staff members’ estimation of weight was poor, with 47% of estimates at least 10% different and 19% of the estimates were at least 20% different from the measured weights.11Another prospective study of adult patients presenting to an urban ED assessed the accuracy of estimations of patients’ weight by the patients themselves, physicians, and nurses in the ED.

In four reports (1.4%), the nurse used the patient’s or family’s acknowledgment of the name, which was incorrect, to verify identity. The authors concluded that when a patient is unable to be weighed, the patient’s own weight estimate should be used.12In a third prospective, descriptive study of trauma patients, healthcare practitioners (physicians, trauma residents, and trauma bay nurses) estimated patients’ weights.
The nurse either confused the patient with a roommate or administered the medication to the wrong patient due to similar room numbers. The nurse did not check the patient’s [ID] bracelet, and the patient received another patient’s morning medications.The patient was in the hall, and the nurse called the name of a patient.
The patient responded “Yes.” The nurse looked at a picture and then asked the patient where her wristband was since it was not on the patient.
The patient was never weighed prior to starting the weight-based heparin nomogram.A patient presented to the ED after having taken an overdose of Tylenol PM. The patient responded, “I took it off a couple days ago.” The nurse looked at the patient’s picture and asked again, “Are you this patient?” The patient responded “Yes” and took the medications without questioning them.
The patient’s initial acetaminophen level [about 100] and an acetylcysteine (Mucomyst®) infusion was ordered based on the established pharmacy protocol.
Later, the nurse realized that the two patients look very much alike.The nurse attempted to administer [a medication]. The nurse asked three adults in the room to verify the patient, since the patient was a pediatric patient and no ID bracelet was on. All three verified and allowed the nurse to give the medication to the patient when it was the wrong patient.The wrong patient profile was viewed on the screen. When the patient reached the floor and was actually weighed, [his or her] weight was found to be 23 kg less than originally stated. The nurse pulled Vicodin® for pain for a patient in 123A but was on the patient in 123B medication profile. The pharmacist was notified, and the infusion rate adjusted based on this knowledge.A report was given to ICU nurse from the ED. The scan matched and at this point, the nurse did not notice that he was on the wrong profile.
This weight was only documented in [the computer system] under the Diprivan® (propofol) medication calculation.
The nurse approached 123A, scanned [the patient’s] bracelet, and administered the medication without checking the screen to see if the correct patient was scanned.Wrong-Patient Errors during TranscribingThe second most prevalent node in which errors originated was transcribing.
Transcribing was defined as the process that involves the transferring of a paper medication order to a patient’s electronic or paper MAR. Nurses, pharmacists, unit clerks, and others can perform this task; however, few of the reports identify the personnel involved. Upon transfer to the bariatric bed, the patient’s weight was confirmed at 250 lb and not 419 lb. Of the transcribing events, most errors were due to transferring orders into the wrong chart (81.4%, n = 253).
According to the ED, the patient’s weight was an estimate because the ED could not weigh the patient prior to administration of the medications.
Various contributing factors were identified, but none were associated with more than 4.1% (n = 4) of reports. In one report, a physician gave a verbal order for a medication but did not use the patient’s full name.
The patient was unable to be weighed due to [his or her] critical status to stand on scale in ED. The pharmacist was notified, who reported that the cardiologist called asking for a “stat” amiodarone for a patient but only gave the patient’s last name.
After the patient arrived to the floor, [personnel] were able to weigh [the patient, whose] weight was recorded as 91 kg.
It was later discovered that the patient was in the registration area but not yet admitted. The doctor had indicated that it was an urgent situation.The doctor came to see the patient, while the nurse was in the room, and discussed the medications he was going to order. For example, when patients are transferred from facility to facility or within a facility between units, practitioners often assume that the weight documented in the medical record is accurate and up-to-date. However, since the patient is in the same room with his wife, the doctor spoke to both of them. When the doctor told the husband what medications he was going to write, he also told them to the nurse and went to the desk to write orders.
One such scenario was reported to the Authority.A patient was admitted through the emergency room. While looking over the copy of the orders, the nurse noticed they were written on an order sheet with the patient’s wife’s ID sticker on it. The demographic sheet obtained from the nursing home, which was used to determine the patient’s weight, listed [the weight] at 253 lb. The nurse went to the wife’s chart and saw that the doctor had written the orders in the wrong chart.
The error was corrected based on correct weight of patient.Although there are studies that show that a patient’s own weight estimate can be more accurate than a healthcare practitioner’s, problems can occur when solely relying on a patient’s stated weight. A filling error is made when a medication prescribed for one patient is dispensed from the pharmacy for a different patient. One example reported to the Institute for Safe Medication Practices (ISMP) involved an ED patient with deep vein thrombosis who purposely understated her weight as 160 lb because she did not want her husband to know that she actually weighed 180 lb. A short time later, a pharmacist working in the unit asked the patient to step on a scale and an error was averted.
While a 20 lb difference in an adult may not cause a problem, larger discrepancies between a patient’s stated weight and a measured weight have been reported to ISMP (up to 100 pounds).14Finally, the patient’s weight may not be communicated to appropriate healthcare practitioners. When I called the pharmacy to inquire about it, the pharmacy said they had no recall of them sending the Levaquin for 465, but they said they did recall that it was sent for 456.
For example, the weight, especially an accurate weight, may not be provided to pharmacy, either on paper or electronically, to calculate or double check weight-based drug doses. In a survey performed by ISMP and the Pediatric Pharmacy Advocacy Group to determine what medication safety practices were in place for pediatric patients in both critical care and noncritical care units, only about half of all respondents reported that the patient’s weight is always entered into the computer before processing orders to allow the system to warn practitioners about drug doses that exceed safe limits.15Errors with Documenting WeightsMost patients are weighed in pounds, both in their home and in the healthcare organization.
A pharmacist who was on the unit was approached by nursing about the delivery of the Fioricet, as it was not in the patient's drawer. But weighing and documenting patients’ weights in pounds introduces the need to then calculate the weight into kilograms, an error-prone process,16 for weight-based and other dosing.
The nurse happened to look in the medication drawer of another patient and discovered the Fioricet.Contributing Factors Associated with Wrong-Patient ErrorsBesides those mentioned above, several contributing factors that span the medication-use process were identified. However, the greater problem is obtaining the weight in pounds then failing to convert and document that weight in kilograms, resulting in more than two-fold dosing errors.
Although the proportions were low, these characteristics were present in events that may have been prevented with system changes (see Table 2).  Table 2. In fact, more than 25% of the 479 reports mention breakdowns that occurred when the patient’s weight, measured in pounds or kilograms, was erroneously documented as the patient’s weight in kilograms or pounds, respectively.
Contributing Factors and Characteristics of Wrong-Patient Errors,  as Reported to the Pennsylvania Patient Safety Authority,  July 2011 to December 2011.In roughly 6% (n = 52) of the events, reporters mentioned that one patient was confused with another because both patients were to receive the same medication.
Reports submitted to the Authority illustrate that this can occur with weights documented in a paper-based patient record or computerized order-entry systems, as well as weights entered into infusion pumps.A patient’s weight was inaccurately reported to the pharmacy using pounds instead of kilograms. While most of the errors occurred during administration, four errors (7.7%) originated during prescribing.
In another example, a nurse confused intravenous (IV) medication bags for two of his patients who were on the same medication. Another nurse did not convert the patient’s weight from pounds to kilograms.A patient’s weight was estimated at approximately 180 lb. Since I was all the way in the back hall, I removed both vancomycin [bags] from the fridge at the nursing station. The nurse did not convert the pounds into kilograms when drawing up the Lovenox® injection. The nurse administered 180 mg of Lovenox.A patient in the ED was ordered “fosphenytoin IV stat” for break-through seizures. ISMP has recommended that verbal orders be limited to use during emergencies and similar situations.12 The following example typifies a verbal order that was transcribed onto the wrong patient’s chart. The resident entered the patient’s weight into the CPOE [computerized prescriber order entry] system in pounds instead of kilograms (44 lb versus 20 kg). The patient received an overdose of the medication that resulted in toxicity.Upon checking IV pump settings, both the weight and kilograms were incorrectly programmed into pump.

Later, another patient was complaining of itching, and the nurse received a report that an order was obtained. Once the correct weight was programmed into the pump, the dose of dopamine was decreased, which decreased patient’s blood pressure, resulting in need to increase dopamine and increase monitoring.Ideal versus Actual Body WeightA third, less frequently reported error involving patient weights is the inappropriate use of either ideal body weight or actual body weight given the patient’s condition or specific medication. For certain types of patients, medications may be dosed on an ideal body weight instead of an actual body weight.
For example, if a patient is dehydrated, his or her actual weight will be lower than his or her ideal body weight, and conversely, a patient who is obese will have an actual body weight that is greater than his or her ideal body weight.
Examples reported to the Authority include the following:Patient was started on a heparin infusion per protocol. The low prevalence may be because many hospitals may already have mechanisms in place to prevent confusion between patients with similar names.
A partial thromboplastin time (PTT) level came back from the lab at high panic [greater than] 249.
In fact, the assumption that similar names are the cause of most wrong-patient errors may result in other failure points being ignored. According to protocol, the heparin infusion was stopped for three hours and another PTT drawn. The example below mentions that two patients had the same first letter of their last names, but this was likely not the only reason for the incorrect transcription.An order for Imodium® 2 mg as needed was entered for the wrong patient on the same floor.
When the second PTT results were reported, the infusion was recalculated and the original calculations were noted to have been made using ideal body weight, when actual body weight should have been used in this case (the actual body weight in this patient was less than ideal body weight). New drip calculations were done and verified with pharmacy, as well as another registered nurse on the unit.The physician ordered “acyclovir 2 gm IV” based on patient’s actual weight of 98 kg.
The order was sent to the pharmacy two more times after the original was entered on the wrong patient. In one example, the confusion involved a discharged patient who had previously occupied the same bed. The pharmacy did not clarify the high dose order with the physician.Risk Reduction StrategiesObtain WeightsIt is vitally important that an accurate weight is obtained when patients arrive at a healthcare facility. Two other examples described insulin pens of discharged patients being dispensed or used on current patients. Even documents from discharged patients were mistaken for those of current patients.During the morning assessment, it was noticed that the previously infused antibiotic syringe on the IV pole with another patient’s name on the medication label was connected to current patient.
Establish a communication process that facilitates the timely transfer of accurate patient weights from nursing to the pharmacy.17Build a hard stop for patient weight into CPOE and pharmacy order entry systems.
The name and date of birth were on the label for a discharged patient, from the previous day, [who had occupied the] same room and bed.The patient in this room was ordered a heparin drip based on an ECG [electrocardiogram] strip on the chart that showed a rhythm of atrial fibrillation. The ECG strip that was on the chart did not belong to this patient but was from the patient who had been in the room yesterday but had been discharged. The heparin drip was ordered this morning by the cardiology resident, and the error was found this afternoon during cardiology rounds by the cardiologist. In a study to evaluate preprinted order forms, a form was designed to guide prescribers through the process of handwriting a complete inpatient prescription by using forcing functions. The patient never received any heparin, and the order was discontinued as soon as it was discovered by the cardiologist.Finally, some reports described events in which patients or their family members caught wrong-patient errors.
To assess the effectiveness of this intervention, medication prescriptions were collected for two weeks before and after introduction of the new forms and evaluated for compliance with medication prescription guidelines. Below is an example that illustrates one such case.I was called to the patient’s room by the wife who noted, within 10 minutes of initiation of infusion, that the IV pump read vancomycin but the medication bag was labeled as acyclovir and with a different patient’s name.
Dose immediately discontinued and no reaction noted.Risk Reduction StrategiesThe reports of wrong-patient events submitted to the Authority reveal the complex nature of wrong-patient medication errors (see Table 3).
While often thought to occur only during administration, these types of errors were identified in all phases of the medication-use process. Descriptions of How Wrong-Patient Medication Errors Occur,    by Node, as Reported to the Pennsylvania Patient Safety Authority,  July 2011 to December 2011     Improve Patient Verification for All Patient EncountersWhile the Joint Commission has an NPSG of improving the accuracy of patient identification, the proper use of two patient identifiers may still not be performed at all times.13,14 Such verification should be considered for all patient-associated tasks, including prescribing, reporting of test results, and communication of medication information between providers.
Several reports illustrate examples whereby patients with similar room numbers or the same drug were prescribed, dispensed, or administered a dose intended for another patient. Overreliance on patient location and the name of the medication ordered may have contributed to one event reported to the Authority about a pharmacy technician dispensing an insulin pen with the label of a previous patient located in the same bed attached to it.
In fact, the Joint Commission’s NPSG requires healthcare practitioners to use at least two patient identifiers (not the patient’s room number or location) when providing care, treatment, and services. If used, clearly label these bins and design them to facilitate medication delivery and retrieval. Moreover, some of the reports describe patients receiving the wrong medication because doses intended for other patients were placed in the former patients’ rooms.Similarly, store and return patient-specific documents in the patient’s chart. For example, a misplaced monitoring sheet may result in an unnecessary treatment for another patient.
Standardizing the labeling practices for paper documents, monitoring sheets, and lab results can decrease the risk of wrong-patient errors.Lastly, institute procedures to remove medications and documents from active patient care areas when patients are discharged. ISMP 2007 survey on HIGH-ALERT medications: differences between nursing and pharmacy perspectives still prevalent.
Bar coding during medication administration can be a reliable double check if performed correctly. Errors in weight estimation in the emergency department: comparing performances by providers and patients. Some of the reports analyzed in this study stated that bar coding successfully detected the wrong-patient error; however, a number of reports indicated that improper use of scanning prevented the error from being caught. In these instances, nurses administered the medication first then scanned the patient’s armband second, or nurses failed to check for a confirmation from the scanning prior to administration.
ISMP has received many reports similar to the latter example and has described this problem in its newsletters.19Hospitals often use ADCs as secure storage units for medications without fully using system capabilities to prevent errors. An ADC that allows nurses to override a majority of medications essentially eliminates a pharmacist’s double check of the prescriber’s order. Standardize policies that detail when verbal orders are appropriate, who may receive verbal orders, how to give and receive these orders, and the safety checks that should be used to prevent error. Estimated height, weight, and body mass index: implications for research and patient safety.
In an earlier example, the prescriber failed to provide appropriate identification and the pharmacist failed to confirm the patient’s identity by reading back patient identifiers in the chart.
They noticed IV bags with labels that had another patient’s name, and in one event described earlier, a family member even noticed the medication mismatch on the IV bag and the IV pump.Establish patient education programs to teach patients the importance of accurate patient identification during all points of contact and how staff should be verifying their identities. For example, if the facility uses bar-code identification, encourage the patient to speak up if his armband is not scanned prior to medication administration. Hospital survey shows much more needs to be done to protect pediatric patients from medication errors. To accomplish this, some organizations have implemented programs in which patients and family members become active partners in ensuring patient safety. These programs include brief safety orientations for the patient upon admission, dedicated hotlines, and educational material listing questions that the patient should be asking the healthcare practitioners who care for them.ConclusionWrong-patient medication errors can occur at any phase of the medication-use process. While events reported to the Authority suggest that these errors occurred most often during administration and transcription, implementing safety strategies at all nodes can help to ensure that the correct patient receives the correct medication.AcknowledgmentsMichael J. Gaunt, PharmD, Pennsylvania Patient Safety Authority, contributed to manuscript preparation.NotesNational Patient Safety Agency. Preprinted prescription forms decrease incomplete handwritten medication prescriptions in a neonatal intensive care unit. He thought the “lady in the door” was the “lady in the window”: a qualitative study of patient identification practices. Understanding and preventing wrong-patient electronic orders: a randomized controlled trial [online]. The use of patient pictures and verification screens to reduce computerized provider order entry errors.
The physician taking care of Patient A asked the nurse to order vancomycin for that patient. The nurse had the electronic charts for both Patient A and Patient B open and accidentally entered the medication on Patient B’s chart.
The pharmacist verifying the order received a duplicate-medication alert from the computer system and realized that Patient B had already been started on vancomycin two days earlier.

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