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First, a note on perspective: The solutions implemented to solve the issues illuminated in a Cause Map are different depending on whose perspective the Cause Map is made from. The Medication Error Reporting Project estimates that confusion surrounding drugs with similar names accounts for up to 25% of medication errors. Taking two drugs that result in a side effect, such as increased blood pressure, could result in that side effect being magnified.
Taking the wrong amount of medication can be caused by getting the wrong dosage, or the wrong frequency. Patient solutions: Remember that sheet where you had the doctor write down all sorts of information about your prescription? Lots of medications, both prescription and over-the-counter, should not be taken at the same time as alcohol. Patient solutions: Ask your doctor and pharmacist about alcohol interacting with medication. Yep, it can happen, especially now that more and more insurance plans are requiring generics be used whenever possible.
Patient solutions: Read that packet of annoyingly small print information that came with your medicine. According to United States Pharmacopeia, 55% of medication errors involve seniors, and 9.6% of these errors caused harm. The first step of the Cause Mapping approach is to define the problem by asking the four questions: What is the problem? We begin the Cause Map by writing down the goals that were affected as defined in the problem outline.
The analysis can continue by asking Why questions and moving to the right of the cause-and-effect relationship above. The patient receives either the wrong medication, the wrong dose of medication, or does not receive needed medication. Because we are attempting a proactive root cause analysis, we can look at the Process Map for steps that could go wrong. The nurse gives the wrong medication to the patient because of an ineffective check of the medication. The nurse may be given the wrong medication because the prescription was filled incorrectly or because the prescription was for the wrong medication. The prescription may be filled incorrectly if the pharmacist grabs the wrong medication (step 10), possibly due to similar looking bottles on the self. Once all these causes have been identified, the next step is to identify solutions to reduce the risk. Solutions 2, 5, 7 and 10 are all process solutions - that is, they add or change steps in the process.
Click here to download the Microsoft Excel workbook showing the outline, Cause Map, and Process Maps discussed above. Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. Deaths due to medical errors in hospitals are higher than certain other causes of death in the U.S. Errors and irregularities in IV drug preparation can have a broad range of consequences ranging from harmless to serious to fatal.


Since the early 70s more and more studies of the quantity of parenteral medication errors have been published30. The majority of medication errors do not occur in emergency situations but while performing routine clinical tasks10. One of the reasons adverse events are so common is that clinicians are human, and thus prone to error. Storage of different drugs, such as high alert drugs (KCl) and standard solution (NaCl) next to one other.
For medication errors, the patient safety goal is impacted because of the potential for patient death or serious harm. The pharmacist selects the medication, measures the medication and then the medication is delivered to the nurse.
Iatrogenic mortality (death caused by medical care or treatment) is now considered thethird leading cause of death in the United States. The National Patient Safety Agency in the United Kingdom has compiled figures showing the type of medication error incidents that actually occur. MedPAC’s proposal involves setting aside an initial 1 to 2 percent of current reimbursement funds and using the money to pay bonuses to those who meet certain quality measures.
A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. The source of these errors can lie at any stage of the process from the initial prescription of an infusion to its administration16. The majority of these errors were medication related and occurred in the hospital setting, harming 1.5 million others who were fortunate enough to escape death.
Wrong transcription and incorrect labeling can both lead to much more severe consequences than simply a wrong drug dose. Measures would include clinical goals as well as process goals, such as using a patient registry to identify patients with diabetes and send care reminders.The justification for the program is not only to improve patient care but also to redistribute payments to physicians and other providers.
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The majority (81 %) of adverse events in their study were associated with one or more human factors, such as lack of knowledge, care or attention. The operative word here is ‘preventable’ since life itself carries risk and unavoidably ends in death for all.
These errors can lead to a mix-up of patients or a mix-up of the prescribed drug, to a wrong application route, a wrong time for application, omission of the drug or even to side effects or infections. It was found that in more than 4,107 cases (28.9 % of total) the most frequent medication error was wrong dose, strength or frequency of the prescribed drug. For example, under the current Medicare payment system, a high-quality physician is paid the same as all others. Of the events that were considered highly preventable, less than 1 % were not associated with human error. Other studies have also found human error to be a key factor contributing to adverse events25-29. Often viewed as the human error factor in healthcare , this is a highly complex subject related to many factors such as incompetency, lack of education or experience, illegible handwriting, language barriers, inaccurate documentation, gross negligence, and fatigue to name a few. There are also many different types of errors ranging from medication errors, misdiagnosis, under and over treatment, and surgical mishaps.


Medical errors are also associated with extremes of age, new procedures, urgency, and the severity of the medical condition being treated.Are medical errors happening more frequently over time? Questions asked involved Medicare policy, such as billing for an office visit and procedure for the same patient on the same day.The GAO cited several factors as contributing to the lack of correct and complete answers. It would appear that way since a 1999 study estimated98,000 iatrogenic deaths making it the sixth leading cause of death in the U.S. Customer service representatives who answer calls must rely on fragments of information from multiple sources and are often interpreting confusing policy information.
The most recent study in 2013 suggested the numbers range from 210,000 to 440,000 deaths per year. Report to the Ranking Minority Member, Subcommittee on Health, Committee on Ways and Means, House of Representatives. The latter number would make it the third leading cause of death after heart disease and cancer. However, which number is accurate? For example, how is it possible to measure deaths due to treatments that should have been provided but were not? Medical records are often inaccurate and providers might be reluctant to disclose mistakes.It might be a waste of time to quibble over the exact numbers since all would agree the numbers are simply too high and unacceptable in our relatively affluent and medically sophisticated society. First, increased cost cutting has certainly contributed to compromised patient safety.  For example, these days, physicians are often being forced to see two or even three times as many patients in a day!
Recognizing that errors are not isolated events as much as part of a process that needs correcting is paramount. Certainly, disclosure and transparency along with checks and balances, without finger pointing, would have the overall effect of improving the chances ‘that mistake doesn’t keep happening.’ Medication errors are far too common. For example, a physician orders the anxiolytic Klonopin 0.5 mg three times daily for a grieving patient for a week.
The pharmacist quickly realizes the unusually high dose of clonidine and in reviewing the patient’s history does not see a diagnosis for hypertension or any other indication for this potent alpha-adrenergic agonist.
Perhaps, since this particular example is a fairly common error, a ‘name alert’ flag could be instituted when either of these drugs is prescribed. However, when the stakes are high whether it be with an airline pilot or a neurosurgeon, ‘oops, I made a mistake’ is simply not acceptable. Placing a higher value on patient safety by tackling these errors at the source may be the only way to prevent the numbers of harmed or dead patients due to medical errors from continuing to climb.00101 Michael Murphy, MD Dr. Murphy served as an Army Ranger for the 1st Ranger Battalion in Savannah, Georgia, which allowed him to gain various leadership skills along with the ability to develop standard operating procedures.
Murphy has been a leader on multiple issues including scribe policy, hospital throughput, electronic medical record implementation and optimization of provider to patient ratios. His goals are to continue making all medical practice locations an environment built for an exceptional patient experience that allows providers to focus solely on patient care.Dr. George's University and completed his residency training in Emergency Medicine at the University of Medicine and Dentistry of New Jersey in Newark.
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