KIMBERLY REED, O.D., FAAO

Prevention of Medical Errors

No financial disclosures

Welcome

• Goals• Fulfill obligation as licensed optometrists• Promote wellness as individuals

• Course Overview and Format• Medical Errors

• Statistics• Types/definitions

• Hospital based errors• Medication errors

• Root cause analysis and prevention• EMR/EHR

• Help or hindrance?

Florida’s requirements

• Florida Rule 64B13-5.001 (8)• Last updated 2006

• “Must include a study of root-cause analysis, error reduction and prevention, and patient safety”

Errors made by our colleagues

Dilated with 1% tropicamide?

Samples of artificial tears?

Expired samples

IOM, 1999: To Err Is Human: Building a Safer Health System

• Between 44,000 and 98,000 people die every year due to preventable errors in U.S. hospitals

Responses to IOM Report

• CE requirements• Mandatory or voluntary systems for

reporting medical errors (National Quality Forum, 2007)

• Joint Commission (JCAHO) requires healthcare institutions to analyze errors using root cause analysis

Responses to IOM Report

• Patient Safety and Quality Improvement Act (database)

• Centers for Medicare and Medicaid Services – will not reimburse hospitals for treatment of 8 preventable errors

• Medicaid, Aetna, BCBS, etc. following suit

Healthcare Associated Infections (HAI)

• 100,000 deaths per year• Leading complication of hospital care

AHRQ.GOV• $50 million annually to research patient

safety• Grants ranging from $400 – 1.2M to study HAI prevention

Agency for Healthcare Research and Quality

Postoperative sepsis per 1000 elective-surgery

Based on income….postoperative sepsis

•Lowest income•Highest income

•Self pay•Medicaid

Children who needed care right away who didn’t get it

• White• Hispanic • Black• English speaking• Non-English speaking

Responses to IOM report

•President Clinton tried to implement mandatory reporting system for medical errors

•Lobbied against by AMA and AHA•81 million dollars

•“If medical errors and infections were better tracked, they would easily top the list {of cause of death in the U.S.}. In fact, a visit to your doctor or a hospital is twice as likely to result in your death [than] a drive on America’s highways.”

Where are we now?

• IOM set a goal of 50% reduction in errors by 2004

HealthGrades Patient Safety (2004)

• Study of 37 million patient records, all Medicare, in 50 states + DC.• Medicare 45% of all hospital admissions excluding OB

• 195,000 deaths annually due to in-hospital medical errors (2000-2002)

• Since the original report in 1999:•1 - 2 million more people have died due to preventable medical errors or hospital-acquired infection

January 2012 report

•Reported January 6 in NY Times•Department of Health and Human Services

•Medicare patients• Hospitals are required to track medical errors and

adverse patient events and conduct a root cause analysis

•Records review by independent doctors•How many medical errors are reported?

Recalculating…….recalculating…..

•130,000 Medicare beneficiaries experience one or more adverse events in hospitals

•EVERY MONTH

Raleigh General Hospital, W.Va.

• Anesthetic Awareness• Patients can feel all the pain, pressure,

discomfort during surgery…but cannot move or communicate with doctors

• Occurs between 20,000 and 40,000 patients every year

• Attributed to physician error or faculty equipment

• Sometimes only part of the drugs are administered

• W.Va. Patient committed suicide

Who makes the IV bags?

• Two year old girl receiving IV chemo• Saline base prepared before adding

chemo agents• Saline was 20 times stronger than ordered

• High concentration of sodium caused brain edema and coma

• Child died 3 days later

Who makes the IV bags?

• Pharmacy tech• High school diploma• Pharmacist overseeing the work was

fired, convinced of involuntary manslaughter

• Jail time• House arrest• Loss of license, career• Fined

Who makes the IV bags?

•Pharm techs have something to do with approximately 96% of pharmacy prescriptions

•“Culture of Silence”

Who is “attending” you?

• Medical Model Education• Student/intern?• Resident?• Chief resident?• Attending?

Who is “attending” you?

• Fatal oversight:• Second year student doing “rounds” at UPenn• 71 year old patient recovering from hip replacement

surgery• SOB, sweating• Classic signs of pulmonary embolism• “I hadn’t read that chapter yet”• Patient died

Adding to the problem

•Most people feel that medical errors are the failures of individual providers• Delays in diagnosis and treatment?

But…

•IOM showed most medical errors are “systems related”

Why do medical errors occur?

• “Systems” errors• Fatigue*

• Brigham and Women’s & Harvard• 3x higher error rate with 1x/ month 24 hour shift• 7x higher error rate with 5x/month 24 hour shifts

• Lack of knowledge• 6000 known diagnoses• 4000 available drugs

• Lack of communication

*www.plosmedicine.org

Why do medical errors occur?

• Poor charting• Impaired care providers

• Survey of 1662 respondents• 46% failed to report at least one serious medical error• 45% failed to report an incompetent or impaired

colleague

*www.plosmedicine.org

Root Cause Analysis

• “A process for identifying the basic factors that underlie variation in performance, including the possible occurrence of a sentinel event.”

• Focuses on systems and processes, not on individual performances

Type of Event Total events 2004-2011

Wrong patient, wrong site, wrong procedure

782

Unintended retention of FB 606

Op/postop complication 604

Delay in treatment 646

Fall 439

Suicide 568

Medication error 319

A Case with a Bit More Relevance

• “The fiasco which left seven veterans blinded”

• Vawatchdog.org

• 62 year old male veteran suffered “significant visual loss in one eye as a result of poorly controlled glaucoma”

• January 2009

A Case with a Bit More Relevance

• In June 2005, the patient was diagnosed as a “glaucoma suspect”

• Allegedly, treatment wasn’t initiated

• Prompted a review of 381 charts• 23 glaucoma patients experienced “progressive visual

loss” while receiving treatment in the Optometry department

• Root Cause Analysis:• Patients were not being sent to ophthalmology for

treatment (required by hospital)• Some OD’s did not hold additional certification to treat

glaucoma

Reality Check – August 9 2010 Archives of Internal Medicine

• Do patients know the name of the doctor overseeing their care?

How many patients know their diagnosis?

•Doctors said

•Patients said

Adverse effects of drugs were discussed with patients?

•Doctors said

•Patients said

Fears and anxieties

•“At least sometimes I discussed patients’ fears and anxieties with them” (doctors)

•“I had fears/anxieties but I didn’t discuss them with my physician.” (patients)

Preventing Medical Errors

Partnership for Patients

• Coalition between 2,900 hospitals and federal administration

• Goal: Reduce medical errors and save 60,000 lives in three years

Reporting Errors

• 27 states have laws that require hospitals to report publicly on infections that are developed in the hospital

• In 2005, only 5 states participated• Obama administration not proposing new

federal requirements for reporting

What can the patient/consumer do to help reduce errors?

• Appoint a patient advocate!• Verify patient’s identity every time a care provider

interacts with patient• Keep a log of doctor and nurse visits and instructions• Get results of all tests and labs• Write down all information pertinent to diagnosis,

treatment, and care• ESPECIALLY medications ordered and dispensed

• Keep a medication log of at-home and hospital-prescribed medications

• Infection Control!

What can the patient/consumer do to help reduce errors?

• Be your own advocate• Choose your hospital wisely

• Most people choose based on doctor’s affiliations, location, or health plan

• Big differences in hospitals: Up to a 30% difference in central-line infections from hospital to hospital

• INFECTION CONTROL!

What can the patient/consumer do to help reduce errors?

• Be mindful of your own medications• Drug errors are a leading cause of error• Bring a list of meds and dosages and keep one with you

during transfers, etc• Know side effects and potential interactions

• Know where your advocate keeps your medication log

What can the patient/consumer do to help reduce errors?

• If you have a choice, choose a hospital using bar-coding to verify patient identity, medication instructions, etc.

• If permitted, label everything you can with patient’s name

What can the patient/consumer do to help reduce errors?

• Avoid wrong-site surgery• Write on your arm/leg/forehead “Operate here”

• INFECTION CONTROL!• Make sure everyone touching the patient washes their

hands• Clean common items in the hospital room such as

television remotes, chair handles, door handles, etc.• Do not allow flowers to be near the patient

Hand washingVideo monitoring improved compliance by 40%

2011 study

•63% of health care workers’ uniforms have CFU’s

•11% multiple antibiotic resistance

•Neckties

57

Stethoscopes?

•1997 study•100% of physicians’ stethoscopes had CFU’s•Mostly staph, strep•simple swabbing with alcohol pad reduced

growth to non-pathogenic

•2011 study of ER workers’ stethoscopes•55% had CFU’s•Mostly staph epi

58

EEWWWWW

• 2010 study• Culture-forming units on• 66% pens• 55% stethoscopes• 48% cell phones• 28% white coats

59

• 2011 study, U of Iowa• 119/180 hospital curtains had CFU’s• 26% MRSA, 44% resistant

Enterobacteria• Takes about a week to contaminate a

new curtain

Coordination of CareWho is IN CHARGE of your health care?

Do all doctors/surgeons agree on the treatment plan?

Who will be responsible for your discharge instructions?

“Guaranteed” outcomes

• Geisinger Health Systems in Pennsylvania• Patients pay flat rate up-front• 90 day guarantee for coronary artery

bypass and other surgeries• If any avoidable complication occurs

within 90 day period, no charge for “remedial care”

• 30-day readmission rate down by 44% since 2006

Bar Coding

• Drugs bar coded in pharmacy based on electronic health record orders

• Patient wristbands scanned before administering drugs

• Alarm sounds if mis-match occurs• Errors cut in half

Improve training

• High-tech simulators• Change the medical model• Change the concept of 24-hour shifts

Lesser-known ways to protect yourself

• Don’t get your prescription filled the first week of the month

• Deaths due to Rx errors are 25% higher• 20 year study

• Don’t get sick in July

Time your illness or accident well

• Babies born late at night 16% more likely to die than those born in the daytime

• California, 2005, 3.3 million babies

• Patients going into cardiac arrest at night more likely to die than those having daytime events

Time your illness or accident well

• More medication errors made by hospital pharmacy at night than during the day

• Kids admitted to pediatric ICU at night were more likely to die within 48 hours

Lewis Blackman

Lewis Blackman Safety Act

MAME

Medication Errors

IOM Report July 2006

• “When all types of errors are taken into account, a hospital patient can expect on average to be subjected to more than one medication error each day.”

Massachusetts

• State Board of Registration in Pharmacy estimates 2.4 million prescriptions are filled improperly each year in Mass.

Common causes of medication errors

• Incorrect drug administration• Name confusion• Lack of appropriate patient education

• Four times a day• Lid scrubs?• “I’m using that cream, but….”• “I’ve used the whole bottle but I still can’t GO!”

• Language issues• Antifungal cream:• Apply once every day

Common causes of medication errors

• Wrong diagnosis• Prescribing errors

• Illegibility• Improper dose (e.g. 5 mg vs 0.5 mg)

• Drug-drug interactions• Dose miscalculations

Most common underlying causes

• Improper dose (40.9%; most are overdose)

• Wrong drug (19%)• Wrong route of administration (9.5%)

• e.g. Otic vs ophthalmic• Vosol vs Vexol

Look-alike, Sound-alike

• Lamictal (antiepileptic) vs. Lamisil (antifungal)

• Celebrex, Cerebyx (anticonvulsant), Celexa (antidepressant)

• Taxol, Taxotere (chemo)• Serzone (depression) and seroquel

(schizophrenia)

“Grievous Personal Injury”

• Durezol vs. Durasol• Salicylic acid wart remover• At least one case of blindness

• Suit reportedly $1M against Walgreen’s in NY• Many other “near misses” reported

Look alike, sound alike

• Methadone (opiate dependence) vs Metadate ER (ADHD)

• 8 year old boy died

Look alike, sound alike

• 4 week old infant• MD ophthal prescribed tobrex

What happened?

•Tobradex instead of tobrex was dispensed….

•And then Refilled

•Infant developed steroid induced glaucoma

WHAT STEPS CAN WE TAKE?

Reducing Medication Errors

2006 report by IOM: Preventing Medication Errors

• 33% of medication errors are from• Naming• Labeling• Packaging

• Accounted for 30% of medication error deaths

IOM recommendations

• Legibility• Avoid abbreviations• Use metric system (not “grains”, e.g.)• Provide patient age and weight when

appropriate• Must include drug name, weight or

concentration, and DOSAGE FORM• Use leading zeros but never trailing zeros

Mind your decimals….

• 0.5 mg NOT .5 mg (leading zero)

• 1 mg NOT 1.0 mg (trailing zero)

Johns Hopkins University

•2006 study•Discharge prescriptions for children requiring “potent, opioid analgesic drugs” for pain management

•How many prescriptions contained errors?

Hopkins

•Most common: •Missing or wrong patient weight•Incomplete dispensing information

•2.9% with potential to cause significant injury

•All prescriptions studied written by residents and fellows without oversight or consultation

Hopkins

• CPOE with decision support• Computerized provider order entry • Reduced med errors in hospitalized

children by 40% - 97%

What about EHR?

• Compared prescribing errors from Sept 2005 through June 2007 for 15 providers who adopted e-prescribing, and 15 who didn’t

• Nearly 4000 prescriptions reviewed

• Two in 5 handwritten prescriptions had errors

March 2010 study, Kaushal et al

• Error rates decreased nearly 7-fold with e-Rx• Down from 42.5% to 6.6%

• Error rates remained the same with paper Rx• 37.3% to 38.4%

• Most errors would not cause serious harm to patients, but could result in pharmacy callbacks/delays/nuisances/inconveniences

• Some errors would have been harmful or fatal

March 2010 study, Kaushal et al

EHR / HIT positives:

• Legibility issues• Dosing errors• Drug-drug interactions• Contraindications• “Pick lists” allow extensive prescription

information with a few clicks

EHR potential pitfalls

• “TMI”• Important data gets buried• Auto-fill even when not appropriate

• A & O x 3???

• Patient history obtained from self??

• Patient denies use of tobacco, alcohol

EHR potential pitfalls

• The “Ignore” Factor• 75% of physicians admit to ignoring

reminder or alert icons• More than half never acted on

information presented in alerts/reminders

Six “Rights”

• Right patient• Right drug• Right dose• Right dosage form• Right route of administration• Right time• “Are you allergic to any medications?”