Pearson: Whether measured relative to its population or its economy, the United States spends by far the most in the world on health care. They use a common fee schedule so that hospitals, doctors and health services are paid similar rates for most of the patients they see. They are flexible in responding if they think certain costs are exceeding what they budgeted for. Pearson: Spending on almost every area of health care is higher in the United States than in other countries. As we have previously said, many OECD countries use strong regulation to set prices that hospitals can charge for different services, and some of them even set budgets for how much hospitals can spend.
Such an approach still leaves room for differences in prices across regions and states, but it could help smooth out some of the huge differences you see in prices paid for the same services delivered in the same hospital, depending on whether a patient is on Medicare, Medicaid or their own health insurer. Pearson: The table below gives some examples of the prices of some common procedures in the United States compared with some of the countries with the best quality health systems in the world.
A coronary bypasses costs between nearly 50 percent more than in Canada, Australia and France, and are double the price in Germany. These procedures and the use of expensive diagnostic tests are all subject to physician opinion on whether they are desirable or not. Payments that mean that physicians get paid more if they do more interventions, regardless of medical necessity.
It is often argued that differences in testing could reflect differences in patients’ needs between and within countries. In terms of health care services, the biggest areas of concern are the quality of primary care services and coordination of care for long-term conditions.
A similar picture emerges for chronic obstructive pulmonary disease (230 admissions per 100,000 population compared to an OECD average of 198, 2009). PBS NewsHour allows open commenting for all registered users, and encourages discussion amongst you, our audience.
The Rundown offers the NewsHour's unique perspective on the important events of the day with insights from the journalists you trust. Use these free images for your websites, art projects, reports, and Powerpoint presentations! 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.
In Japan, if spending in a specific area seems to be growing faster than projected, they lower fees for that area.
In running their business, private health insurers continually face a choice between asking health care providers to contain their costs or passing on higher costs to patients in higher premiums.
It is often comforting to feel that medical problems are being diagnosed or treated, regardless of whether they are medically necessary. However, research at the Dartmouth Institute has documented that there are large variations in medical practice across different regions in the United States which cannot be explained by differences in population structure or differences in illness.
Support for physician counseling and programs to help encourage healthier lifestyles vary widely with different insurance arrangements.
OECD Health Data shows that the five-year survival rate for breast cancer is higher in the U.S. Along with the FDA’s comparatively shorter drug approval processes, this means that cutting-edge drugs and treatments are available more quickly to American patients than elsewhere. Innovative centers such as the Mayo Clinic and Johns Hopkins that bring laboratory research and clinical practice together have also benefited patients enormously. Examples that the world is watching at the moment include Accountable Care Organisations, which seek to better manage risk-sharing by giving providers flexibility to coordinate and deliver health care while holding them accountable for costs and outcomes and the Medical Home model, which seeks to coordinate care and better engage patients and families, using health coaches, care transition pathways and other interventions to reduce expensive re-hospitalizations.
While many states are making efforts to reduce smoking, there are fewer policies to tackle the harmful use of alcohol in the U.S. In a Commonwealth Fund survey of seven nations (Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States), 16 percent of American patients reported delays in being notified about an abnormal test result (the highest proportion reported) and only 75 percent of primary care physicians reported often or always receiving correspondence from specialists after referral suggesting systemic problems with care coordination. The average spending on health care among the other 33 developed OECD countries was $3,268 per person.
Not only does this cut down on medical errors, it is also thought to save 1-2 hours of work by the pharmacists per day. Groups of insurers and hospitals across different regions then use the national government’s ranking to negotiate what prices they ought to pay across the board.
More generally, with so many different kinds of insurance, no one organization has a strong incentive to cut out wasteful practices and ensure that all Americans get value for the very high levels of expenditure incurred when they are sick. Similarly, regional variations in hip and knee replacement are substantial, with the rates four to five times higher in some regions compared with others in 2005-06. Adult overweight and obesity rates are the highest in the OECD, and have kept growing even in the last couple of years, while they have nearly stabilised in some other OECD countries, such as England, France and Italy.
Anti-infectives, opioids, and anticoagulants were the most common types of medications associated with wrong-patient events. For example, they monitor how many generic drugs a physician is prescribing and can send someone from the insurance fund to visit physicians’ offices to encourage them to use cheaper generic drugs where appropriate. When we look across a broad range of hospital services (both medical and surgical), the average price in the United States is 85 percent higher than the average in other OECD countries.
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.
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. Both height and weight are needed to use nomograms to determine body surface area and body mass index.
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.
A Look at the NumbersThere is little information in the literature that specifically mentions medication errors that result from missing or inaccurate patient weights.
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). 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. Almost 13% (n = 104) of reports listed anti-infective medications as being involved in the event. A national survey of EDs shows that more than 50% of all patients admitted to a hospital came through the ED. Of the reports involving a known single medication, almost 30% (n = 169) were associated with high-alert medications.
Units Commonly Involved in Medication Errors Involving Wrong Weights (n=259) A review of the medications commonly reported reveals two key attributes. The third most common care area noted in the reports was the emergency department (9.8%, n = 80). Second, 5 of the top 10 medications involved, representing 236 (49%) of all reports, are high-alert medications. 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. 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.
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. Monitoring is defined as patient assessment activities that occur before or after administration of medications. 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 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.
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.
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 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 “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’s initial acetaminophen level [about 100] and an acetylcysteine (Mucomyst®) infusion was ordered based on the established pharmacy protocol.
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.
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.
When the patient reached the floor and was actually weighed, [his or her] weight was found to be 23 kg less than originally stated. 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. The pharmacist was notified, and the infusion rate adjusted based on this knowledge.A report was given to ICU nurse from the ED. The nurse pulled Vicodin® for pain for a patient in 123A but was on the patient in 123B medication profile. This weight was only documented in [the computer system] under the Diprivan® (propofol) medication calculation.
The scan matched and at this point, the nurse did not notice that he was on the wrong profile.
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.
Upon transfer to the bariatric bed, the patient’s weight was confirmed at 250 lb and not 419 lb. Nurses, pharmacists, unit clerks, and others can perform this task; however, few of the reports identify the personnel involved. 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. 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.
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. However, since the patient is in the same room with his wife, the doctor spoke to both of them. One such scenario was reported to the Authority.A patient was admitted through the emergency room. 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. The demographic sheet obtained from the nursing home, which was used to determine the patient’s weight, listed [the weight] at 253 lb. 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 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.
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 filling error is made when a medication prescribed for one patient is dispensed from the pharmacy for a different patient. 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.
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. 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. 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. 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. 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. 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.
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. 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. Although the proportions were low, these characteristics were present in events that may have been prevented with system changes (see Table 2). Table 2. 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. 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. 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.
The nurse did not convert the pounds into kilograms when drawing up the Lovenox® injection.
Since I was all the way in the back hall, I removed both vancomycin [bags] from the fridge at the nursing station. The nurse administered 180 mg of Lovenox.A patient in the ED was ordered “fosphenytoin IV stat” for break-through seizures. 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). 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 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. 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. Later, another patient was complaining of itching, and the nurse received a report that an order was obtained.
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. A partial thromboplastin time (PTT) level came back from the lab at high panic [greater than] 249.
The low prevalence may be because many hospitals may already have mechanisms in place to prevent confusion between patients with similar names. According to protocol, the heparin infusion was stopped for three hours and another PTT drawn. In fact, the assumption that similar names are the cause of most wrong-patient errors may result in other failure points being ignored. 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). 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. 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. 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. In one example, the confusion involved a discharged patient who had previously occupied the same bed.
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. 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 heparin drip was ordered this morning by the cardiology resident, and the error was found this afternoon during cardiology rounds by the cardiologist. 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.
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.
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.
ISMP 2007 survey on HIGH-ALERT medications: differences between nursing and pharmacy perspectives still prevalent.
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. Errors in weight estimation in the emergency department: comparing performances by providers and patients. Bar coding during medication administration can be a reliable double check if performed correctly. 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.
Estimated height, weight, and body mass index: implications for research and patient safety.
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. 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. Hospital survey shows much more needs to be done to protect pediatric patients from medication errors. 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.
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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