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Medical errors are not legally required to be reported in the event of death, but these mistakes are frequent and can be fatal. If medical errors result in this many deaths, the severe injuries they cause are significantly more prevalent. If you think you that you or a loved one has experienced the ill effects of a medical error, you may be able to mount a successful case.
Filed Under: Medical Errors, Medical Malpractice, Personal Injury Attorney Do I Need a Lawyer?
The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. 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. The study compared financial characteristics of people under age 65 in Massachusetts to other New England states, before and after full implementation of the Massachusetts health care law in 2008. Just to be sure about health reform’s causal effect on improved financial well-being, the authors conducted an analysis of individuals over age 65 in Massachusetts, since this age group was essentially unaffected by the reform.
Our analysis shows that health care legislation has implications that reach beyond health care providers and the uninsured, and extend into credit markets, benefiting not only uninsured households who gained coverage, but also creditors who served these households. Particularly striking is the fact that these financial improvements took place in the midst of a serious economic recession.
Again, Massachusetts leads the way in demonstrating the far-reaching beneficial impacts of universal healthcare.
For several years, Massachusetts has operated an academic detailing program, operated by the Department of Public Health. Last week, the legislature overrode the veto, by a 122 to 31 vote in the House, and a 36 to 3 vote in the Senate. HCFA continues to press for effective prescription drug policies that save money and improve care.
There is currently a significant opportunity to elevate oral health in health care here in Massachusetts. MassHealth’s released Waiver Proposal touches upon oral health in a few important ways, and briefly outlines the inclusion of oral health metrics in the ACO quality measure slate as well as contractual expectations for ACOs around oral health. OHIP submitted formal comments to MassHealth pushing for more robust ACO standards that would facilitate increased integration of oral health. Health Connector Executive Director Louis Gutierrez provided updates on Connector activities. The Health Connector is considering their options to the Small Business Health Options Program (SHOP) and employee choice program. In response to the SHOP updates, Board members discussed and inquired as to whether implementing a SHOP system would be a waste of time and money and whether this feature of the ACA is able to be waived.
Ed DeAngelo and Ashley Hague presented proposed updates to the Health Connector Board bylaws, which have not been updated since the Connector’s inception in 2006. In response to the 2017 Seal of Approval RFR, there will be a 25% decrease in health plans offered through the Connector when compared to 2016.
Notably, one of the new goals of the SoA expressed by the Health Connector is  enhanced substance use disorders treatment 2017 ConnectorCare plans will offer enhanced access to Clinical Stabilization Services and reduce the cost burden for key MAT (medication-assisted treatment) and associated services. Another change is the requirement for QHPs to include pediatric vision and dental services, as per the State’s updated Essential Health Benefits (EHB) requirement Requiring Pediatric dental EHB coverage would move the Health Connector into parity with the off-exchange market, increasing the accessibility of these services. New residents at BMC attend orientation, which includes a workshop on the social determinants of health. Last week WBUR reported on an effort to improve doctor-patient relationships by training medical professionals in social determinants of health. Everyone in Massachusetts deserves the opportunity to lead a healthy life, and it is in our best interest for all doctors to be trained in how health may be affected by social factors. Over 50% of affiliated doctors at some Massachusetts community hospitals received payments. At some hospitals, almost everyone was on the take: 77% of doctors at Baystate Noble Hospital in Westfield received payments, mostly in the form of meals.
Most meals were provided while drug industry representatives provided information on brand name medications for asthma, high cholesterol and blood clots. The Globe reached out to two doctors who each reported over 200 meal payments during 2014 for comment, but they refused to return multiple emails and phone calls from the paper. While state law limits drug marketers to providing "modest meals" as part of educational forums, we reiterate our call to tighten the state regulation of what's modest. MassHealth staff started with this powerpoint presentation, which summarized the waiver application.
Many speakers focused on the opportunity to expand MassHealth to provide assistance with the social determinants of health, like housing, nutrition and other social services. We have heard the strong emphasis from the administration on ACOs as a way to improve MassHealth’s “sustainability,” which, of course, is code for saving money. We understand and support this goal, and we also understand the need to secure federal DSRIP funds.
Address the opioid crisis by expanding access to a broad spectrum of recovery-focused substance use disorder services.
Our comments today will focus on 3 areas where we think the waiver can be strengthened, consistent with the goals of the project. Before I get to our three categories, I want to mention that we also have critical thoughts on the integration of oral health and dental care within the ACO structure. The study found that doctors who received industry sponsored meals were significantly more likely to prescribe brand-name medications, compared to doctors who did not receive industry sponsored meals. At HCFA, we are dedicated to advocating for high-quality healthcare at the lowest possible cost to the consumer, which is why we were steadfastly opposed the weakening of our gift ban law in 2012. With costs of MassHealth rising steadily, it is crucial we find patient-centered ways to control costs.
The recently released Indiana Medical Errors Report provides good news for your hospitalized patients.
Since 2007, hospitals, ambulatory surgery centers, abortion clinics and birthing centers have been required to annually report errors. While there were no medication errors resulting in death or serious disability in 2010, three were reported last year. The requirement to report events identifies persistent problems, encourages increased awareness of patient safety issues and assists in the development of evidence-based initiatives to improve patient safety. Medical errors generally are not the sole result of actions of individuals, but rather the failure of the systems and processes used in providing health care.
Medical errors generally occur not from one person’s mistake but from failures of systems and processes. Since 2005, Indiana health care facilities have been required to report events as a way to increase awareness of patient safety issues and improve care. In the five years since reporting began, pressure ulcers have been the most persistent problem, and the numbers are up in this category for 2010. The number of falls resulting in death or serious disability was up considerably, from 8 in 2008 and 2009 to 17 in 2010. We have explored in previous writings how biological systems and human physiology can model elegant solutions for the design and operation of complex hospital buildings, suggesting ideas for non-disruptive alarm signals, mechanical systems monitored by information technology to increase patient safety, and heating and cooling layouts that conserve energy.
Another essential component of safe patient care is prompt reporting of medical errors, errors that may or may not have actually harmed the patient. Despite both mandated and voluntary reporting protocols, finding accurate data on the number and cost of medical errors is almost impossible. Clinicians avoid reporting errors because they fear damage to their reputation and career, as well as litigation, or they lack training on how best to handle these difficult conversations. Can mammalian physiology model a solution to this cultural and behavioral problem universal in healthcare? The kidney is a remarkable organ, responsible for both filtering soluble waste products from our blood and for maintaining a strict fluid and chemical environment in order for us to survive. If your hospital or institution has already embarked on creating a protected zone where errors can be revealed and understood for improved patient safety, please share your ideas below so others can join you in this work. Shocking but true, a new study led by researchers at the Johns Hopkins University School of Medicine suggests that routine medical errors are third on the list of leading causes of death in the United States, surpassed only by heart disease and cancer. Unfortunately, many of these errors go unreported and those responsible are rarely held accountable. These reports were analyzed to classify the events by node, related processes, possible causes, and contributing factors and to detect trends and noteworthy cases.
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. Confirming the findings, seniors’ financial outcomes did not change relative to those who gained access to insurance under the reform.
Our finding that credit scores improved as a result of the reform indicate that the reform increased future access to credit for those individuals who gained coverage.
It prompts the question: did the 2006 health reform help mitigate some of the recession’s worst effects for the state of Massachusetts? Through the 1115 waiver, MassHealth is requesting authority from the federal Centers for Medicare and Medicaid Services (CMS) to restructure MassHealth care delivery through implementation of Accountable Care Organizations (ACOs) and expand substance use disorders services. Health Care For All helped draft and submit several sets of comments on a range of issues covered in the waiver proposal, with common themes around ensuring access to care, member choice, consumer protections, and monitoring and oversight. CMS will send MassHealth a notice of receipt within 15 days of submission, and that notice initiates the start of a 30-day federal comment period.
And with HCFA’s support, the Massachusetts state legislature just saved its funding for this year.
Detailers are sales representatives who travel to physician practices to deliver sales pitches lauding the benefits of their drugs. Independent experts meet with doctors, and go over current scientific information on a class of drugs, informing doctors on all the research, and making unbiased recommendations based on comparative evidence, including cost-effectiveness.
For this coming fiscal year, the plan was to focus the $150,000 program on how to best prescribe pain killers, to avoid the over-prescribing of prescription opioids. In addition to support for academic detailing, our prescription drug policy agenda includes greater transparency around drug prices, and eliminating copays for cost-effective preventive care. OHAT’s new Oral Health Integration Project (OHIP) kicked off this past May and has hit the ground running. As explained in previous blog posts, MassHealth is proposing substantial changes to its program with the renewal of its 1115 Demonstration Waiver, to be approved by the federal government.
OHIP is pleased to see that oral health is included in MassHealth’s future plans for restructuring and is urging MassHealth to expand its efforts in this area.
Gutierrez responded that it is waivable under Section 1332 authority, but it would be very difficult to obtain approval. The next release in August will focus on repairs and user experience upgrades to prepare for 2017 Open Enrollment, allow for Spanish language notices, and plan management features. Updates focused on the designation of the Secretary of Health and Human Services as the board chair, the allowance of Board members to be notified of scheduling matters via email, the shift of responsibility from Executive Director to a Health Connector employee to be responsible for meeting minutes, and the allowance of the election of a vice chair to occur any time during the final quarter of the year, depending on each monthly agenda were each enacted. This included the an update to the minimum dollar value (from $5,000 to $15,000) for contracts that do not require a formal vote, but do require a written notice to the Board 5 days before execution. Unlike 2016, when only non-standardized Bronze plans were offered, the Health Connector created, two new Standardized Bronze plans - one MCC-compliant and the other  has-compatible. While one carrier cited operational challenges as a barrier, most opted to include pediatric dental benefits into their plans. HCFA was a major force behind the passage of the 2008 law that required all Massachusetts hospitals to establish PFACs, and for the past eight years, has provided technical assistance, training and networking opportunities to strengthen patient and family engagement in hospitals.
According to the Agency for Healthcare Research and Quality, PFACs are bodies made up of individuals who have received care at a hospital (or their representative family members) and are able to offer feedback and insights to inform and improve hospital care delivery, policies and operations to most effectively address patient and family needs and preferences.


These recognize that our health is largely determined by our access to social and economic opportunities, not direct medical care. By looking at health from a more holistic perspective, health care professionals can aid in the transformation of the medical system and improve health outcomes. At Mercy Medical Center in Springfield, it was 74%; at Harrington Memorial in Southbridge, it was 71%. After all, the state definition was drafted in consultation with pharma lobbyists, and it essentially imposes no real limits.
The session was held in conjunction with the regular meetings of two MassHealth advisory panels. People representing YMCAs, the Housing and Shelter Alliance, the Pine Street Inn and other groups talked the critical role housing and other services play in promoting health. Those issues will be addressed by representatives of the oral health integration project which we lead. The answer is simple – it is a not-so-subtle form of bribery designed to influence prescribing practices. Sure enough, doctors who were better fed, receiving either more or pricier meals, displayed an even higher likelihood of prescribing the advertised drug.
The original law forbade pharmaceutical companies from providing doctors with free meals or other forms of payment, with the goal of preventing doctors from being tempted into prescribing more expensive drugs with no additional clinical benefit.
Consider a Medicare patient who is prescribed an expensive brand-name drug when a cheaper, equally effective alternative is available. That means members of the health care community must keep focusing on fundamental prevention activities – organizing systems to reduce or even eliminate medical errors. The annual statewide report is based on the National Quality Forum’s (NQF) listing of 28 serious adverse events. A change in standards to be more consistent with the NQF likely impacted these numbers, according to the Indiana State Department of Health.
Collecting this data is essential so that physicians and nurses can understand and correct the underlying causes for the error. Recently a comprehensive tool, the Institute for Healthcare Improvement released the Global Trigger Tool, developed to capture data on errors.
How can an environment protected from these pressures be created, one that encourages clinical staff to view errors as opportunities to improve the system rather than as personal failures? This balance of fluid intake with urine output must occur despite widely varying outside climates to protect us from dehydration in dry environments as well as from over-dilution and bloating when large volumes of fluids are consumed. This zone, known as the renal medulla, is where chemical products and fluids are balanced, operating as if oblivious to the conflicting concentration gradients in cells only millimeters away. Only with these safeguards in place can clinicians and administrators reveal, analyze, and learn from these events, ultimately preventing future tragic results from accidents caused by human and system errors. According to the study, medical errors likely cause more deaths than automobile accidents, stroke, respiratory disease, or Alzheimer’s. For the sake of all of us who rely on medical professionals, this is an issue that studies such as the Johns Hopkins one seek to address. 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.
Before the reform, from 1999-2005, Massachusetts followed the same financial trends as other New England states. These results show that health care reform legislation has pervasive effects not just on health and the use of health services, but across many measures of household well-being. Common sense economics says that if people have less bad debt, less likelihood of declaring bankruptcy, and better credit, they will have better economic opportunities. MassHealth is asking CMS for a $1.8 billion up-front investment over five years to support transition toward ACO models, including direct funding for community-based providers of behavioral health and long-term services, as well as funding for for safety net programs, including the Health Safety Net – this is important, as under the current waiver, a significant portion of Safety Net Care Pool funding is set to phase out by June 30, 2017. Often, detailers provide a free meal and drug samples as an enticement for providers to listen to their spiel. But when the fiscal year 2017 budget was presented to Governor Baker, he vetoed the funding for the program.
We’re very pleased that the academic detailing program survived, and will continue to press for a consumer-focused policies in this area. Over the past couple of months, OHIP members and stakeholders have put their heads together to think about what oral health that is fully integrated with the rest of the health care system could look like. At stake is 1.8 billion dollars over five years to support MassHealth’s transition to Accountable Care Organizations (ACOs). The Health Connector is considering a shared platform with other states such as Connecticut, Rhode Island and Washington DC as an alternative.
The type of “contract” requiring Board vote was then specified as “any and all types” except for extensions, amendments and work orders that cost less than a quarter of the original contract, as long as the cost is noted in the most recent Board approved fiscal budget. On the dental carrier side, there were not many changes to the requirements and offerings of Qualified Dental Plans (QDPs).
PFACs have the potential to help improve overall systems and processes of care, which can lead to better health outcomes for patients, as well as improve financial performance of health care organizations.
Some of these factors include access to housing, nutritional food, education, and income supports, among many others. And this new research points to the need to also curb the number of meals provided, as well as the cost per meal. Despite it being a late Friday afternoon before the first weekend of the summer, interest in the proposal was very high. MassHealth is seeking $1.8 billion over 5 years from the federal government to be used for Delivery System Reform Incentive Payments (DSRIP).
Similarly, Action for Boston Community Development suggested creating social service "hubs" to connect medical ACOs with smaller agencies which can focus on particular needs.
In the coming weeks, we will be circulating a sign-on letter for groups to join us in expressing broad community reactions to the waiver proposal. It’s an opportunity to restructure care so that the focus is on promoting the health of MassHealth members. We also strongly support the comments you will receive from groups concerned with community health workers, the disability community and the public health community.
The association held for four brand-name medications, including rosuvastatin, the third most expensive drug for Medicare Part D. The weakened law allows for "modest meals," but the regulations effectively put no limits on what can be provided. A total number of 100 adverse events, down from 107 in 2010, were reported by 291 health care facilities.
No medication errors resulting in death or serious disability were reported in this most recent year.
This tool, which still underestimates the true incidence of mistakes, revealed that less than 10% of errors are actually reported! When we drink excess water, the kidney can excrete very diluted urine with a concentration of about one-sixth of the rest of body. Anti-infectives, opioids, and anticoagulants were the most common types of medications associated with wrong-patient events.
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. Greater numbers of economically healthy individuals means a more prosperous economy as a whole.
One study from Harvard Medical School found that each dollar spent on academic detailing saved two dollars in prescription drug costs. ACOs are a new way to pay for and deliver care that works by bringing together providers to coordinate high quality health care – care that we believe should include oral health. One Board member questioned whether the IT system will be impacted by MassHealth’s delivery system redesign and implementation of Accountable Care Organizations (ACOs).
This piece highlights a program that is being implemented at Boston Medical Center, in which resident doctors are being trained to find out what kinds of barriers their patients may face when it comes to being healthy and staying healthy.
Given the number of speakers, the session, which started at 2:30 was supposed to go to 4, dragged on until almost 5. These funds will support the transistion to ACOs (Accountable Care Organizations - see our blog post here for more on ACOs).
The Boston Center for Independent Living and the Transformation Center talked about the needs of people with disabilities. Health is more than just what doctors and hospitals do, though they are important. ACOs open the door to a MassHealth system that treats the member as a whole person, rather than as disconnected symptoms. Or should they be relying on the latest peer-reviewed scientific studies, weighing the evidence of a multitude of more objective sources? Therefore, in return for a small investment in the form of free meals, pharmaceutical companies receive a generous taxpayer subsidy.
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.
In total, 10 medical carriers responded to the 2017SOA ,submitting 62 QHPs for both non-group and small group shelves. The conference covered a lot of ground across these three themes, providing the nearly 300 participants with opportunities to discuss everything from building internal credibility for PFACs, to creating effective meeting agendas, to understanding why PFACs should care about and provide their perspectives around quality measures. In an effort to improve patient-centered care, similar trainings to the one at BMC are also being offered to doctors at various hospitals around the country, including Johns Hopkins in Maryland and at Dell Medical School in Texas.
Money will go to provider groups seeking to become ACOs, allowing them to pay for social services as well as medical care. Doctors who are wined and dined – even when it costs less than $20 – are more likely to prescribe brand name, highly expensive medications. Clearly, for patients to trust their doctors, the integrity of medical information dissemination must be preserved. Incredibly, the kidneys maintain this hydration balance while processing more blood and bodily fluids than any other organ in the body; 180 liters or 47 gallons per day of which 99% is reabsorbed back into our body. At the very least, there needs to be a core attitude of trust and openness for the physicians, nurses, and administrators. 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.
With this medical errors stands as the third leading cause of death after myocardial infarction and cancer. An important new study, The Effects of the Massachusetts Health Reform on Household Financial Distress, published in the American Economic Journal, sheds light on the economic impacts of the 2006 Massachusetts health reform. Most importantly, the conference provided PFAC members from across the state with an opportunity to network with – and learn from -- one another.Read more about Purposeful. Funds will also go towards integrating behavioral health and long-term care services, and other investments, In addition to the DSRIP money, the state is seeking $6.2 billion over 5 years for safety net providers and to pay for care for the uninsured.
The kidney accomplishes this filtering and concentrating feat in the midst of tightly regulated surrounding tissues.
The conclusions suggest that the effects of sweeping health reform extend far beyond better health outcomes; expanding coverage may actually help to lift people out of the hole financially, ultimately driving opportunity for economic growth.
Less personal bankruptcy means – well, let’s just say we know what happened in the 2008 financial collapse. 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. 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. 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).
Almost 13% (n = 104) of reports listed anti-infective medications as being involved in the event.


Of the reports involving a known single medication, almost 30% (n = 169) were associated with high-alert medications.
The third most common care area noted in the reports was the emergency department (9.8%, n = 80). 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. 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. 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.
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 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 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. 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 nurse pulled Vicodin® for pain for a patient in 123A but was on the patient in 123B medication profile. 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. 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). 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 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. 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. 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. 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. A filling error is made when a medication prescribed for one patient is dispensed from the pharmacy for a different patient. 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. 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.
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. Although the proportions were low, these characteristics were present in events that may have been prevented with system changes (see Table 2).  Table 2.
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. Since I was all the way in the back hall, I removed both vancomycin [bags] from the fridge at the nursing station.
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.
Later, another patient was complaining of itching, and the nurse received a report that an order was obtained. The low prevalence may be because many hospitals may already have mechanisms in place to prevent confusion between patients with similar names. In fact, the assumption that similar names are the cause of most wrong-patient errors may result in other failure points being ignored. 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. 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.
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. 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. 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. 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.
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. 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.
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.
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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