Articles: Medical Errors
Improving the Quality of Health Care: A Mandate for
Nursing
By Kathleen Ashton, RN PhD and Patricia
Iyer RN MSN LNCC
This article contains the text of the paper that Patricia
Iyer presented at the ICN conference in Copenhagen, as well
as photos from conference itself.
The
American health care system is undergoing a strenuous self-examination
as a result of attention being drawn to medical errors.
The findings of a study performed with 1984 data, the Harvard
Medical Practice Study, showed that nearly 4% of people
who are hospitalized have an adverse event. A random sample
of 30,000 patients from a random sample of 51 hospitals
in one state, New York, was selected for this study. Medical
records were examined to detect evidence of adverse events.
Based on that data, the researchers concluded that 1.3 million
people in 1984 were injured each year from adverse events,
approximately 120,000 died. According to the Harvard Medical
Practice Study, about 6.5 % of patients admitted to hospitals
in 1984 had an adverse
drug event and about one third were preventable.
 The actual number of deaths projected by the Harvard Medical
Practice Study is believed to be underestimated. The retrospective
review of medical records in this study did not reveal all
of the adverse events, as much relevant information is not
contained in medical records. The actual numbers of people
dying each year in the United States may be 200,000 or more.
The frequency of adverse events is believed to be higher
now that it was in 1984 due to the increasing complexity
of medicine, and care being delivered to sicker patients
in today’s American hospitals.
The
cost of the adverse events detected by the Harvard Medical
Practice Study was roughly $50 billion. At least two thirds
of these events were preventable. With inflation, using
1998 dollars, the cost of adverse medical events was about
$100 billion. The costs of these errors include unnecessary
health care expenditures, disability and lost productivity,
which add up to billions of dollars.
 There
are also costs associated with defending medical and nursing
malpractice cases. In the American legal system, the defense
of the nurse is paid for by insurance premiums. Some nurses
have their own insurance, but most rely on their employer
to pay the premium. The defense attorneys bill by the hour
to defend the nurse. The plaintiff attorney pays for all
costs associated with the lawsuit, which may run $50,000-$100,000
or more. If the attorney is able to achieve a settlement
without going to trial, or wins at trial, the attorney is
reimbursed for the expenses and gets a percentage of the
money, typically one third. In 2000, the median for verdicts
for medical malpractice cases was $800,000 dollars. This
system requires careful selection of cases and attorneys
who are able to pay for the costs of a suit without assurance
of winning.
A series
of well-publicized adverse health care events occurred in
1995, which began the heightened awareness of patient safety.
The Joint
Commission for Accreditation of Healthcare Organizations
accredits a wide variety of healthcare organizations including
hospitals, nursing homes, home care agencies, and clinics.
Concerned about the problem of medical errors, in the late
1990’s the Joint Commission enforced a mandatory system
of reporting medical errors or sentinel events. The healthcare
organization is required to perform an analysis of the error
and to define the preventive action needed. The Joint Commission
acknowledges that no one has a real accurate understanding
of the numbers of errors because all of the incentives
to report an error are negative.
Between
January 1995 to January 2001, a total of 1099 errors were
reported to Joint Commission. Sixty five percent were voluntarily
reported to comply with the sentinel events reporting policy,
and the media was responsible for identifying 16 percent.
The rest were detected through complaints, during a survey
or through other means. Medication errors made up 12.6%
of reported errors with 138 medication errors reported during
this 6-year period.
Clearly
these numbers do not represent all of the medication errors,
but they do include serious errors. Medication errors are
among the most common reasons why patients are injured.
(For more information on medication errors, see Pat Iyer's
video
on the subject, available at our webstore.)
Inappropriate drugs are associated with falls and other
problems in up to 20% of nursing home residents. The US
Pharmacopeia collects data that is voluntarily and anonymously
reported from hospitals. In 1999, 6224 errors were reported.
The vast majority of medication errors in 1999 showed that
97% did not result in patient harm or death, but 3% did
result in temporary damage or death.
However,
research has also confirmed that many medication errors
go undetected, including those that harm patients. Even
when the errors are detected, they may not be reported.
Studies have shown that only 5% of medication errors are
reported. Healthcare organizations persist in disciplining
nurses who report errors by disciplining, suspending or
firing them or reporting the error to the licensing board.
Relying on incident reports is the least reliable method
of detecting errors. In several studies, the observation
method yielded the highest error rate detection.(See Pat
discussing medication errors on
TV.)
There
are a few medications that are frequently involved in medication
errors, including Heparin, potassium chloride, insulin,
narcotics, and sodium chloride solutions above .9 percent.
Removing hypertonic solutions and electrolytes for IV administration
from nursing units has resulted in a reduction of errors
involving these products. The most frequent types of medication
errors are failure to administer an ordered drug, improper
dose or quantity, and giving a drug that was not ordered.
 Medication
errors represent problems at several levels of the healthcare
system. Errors at the prescribing stage have been reported
in the literature as one level where improvement is needed
(Bates, et al, 1995, and Edes & Sunderrajan, 1985).
Pantaleo and Talan recommend improving systems and providing
education at this level to prevent and reduce errors. In
response to the problem, one institution found that placing
a pharmacist in close proximity to serve as a resource for
physicians, nurses and patients during medical rounds can
improve the medication order process (Pantaleo & Talan,
2000).
In addition
to the specific medications previously mentioned, certain
devices are also implicated as high-risk for medication
errors. Patient controlled analgesia pumps are included
in this category. Pumps are programmed to prevent accidental
over dosage. However, the possibility for error exists in
programming concentrations of solutions, and in the rate
of administration. Nurses must verify concentrations and
calculate dosage limits whenever they check the pump, usually
at four-hour intervals. Other pumps used for IV drug administration
have been implicated in medication errors. This realization
has prompted hospitals to abandon the use of IV pumps that
allow free flow of fluids in favor of devices which control
fluid rates.
Another
important method to reduce errors is to adhere to the traditional
"five rights" when administering medications –
the right patient, the right drug, the right dose, the right
route, and the right time. Checking the patient’s identification
band can help verify patient identity. Checking the drug
label three times – before, during and after administration
– can help to assure the right drug is administered.
This procedure has been recommended by the 17-member National
Coordinating Council for Medication Error Reporting and
Prevention (Morris, 1999).
In some
institutions, the identification band can now be used in
an electronic check of the medications being presented to
the patient. The nurse scans the patient’s identification
band with a hand-held scanner and the bar code is matched
to the medications, similar to the devices used in supermarkets
to determine the correct price of items. This system helps
to assure that the correct medications are being administered,
but does not negate the nurse’s role in checking for
side effects and other aspects of safe medication administration.
This system is costly and has been implemented in only a
few settings. The Veterans’ Administration system is
currently using the system with favorable results.
A thorough
history is invaluable in helping to spot medication interactions,
omissions and potential problems. It also forms the basis
for patient teaching to enable the individual to continue
safe medication practices upon discharge. Accurate and thorough
documentation of all medications is critical in helping
to reduce errors and in supporting the nurse’s role
in medication administration.
While
humans will continue to make mistakes, systems can be designed
to keep errors to a minimum. This approach focuses on "fixing
the system" as opposed to the current "shame
and blame" approach of placing blame on the provider.
Fixing the system has been shown to be significantly more
successful. The Joint Commission on Accreditation of Healthcare
Organizations requires hospitals to conduct a detailed analysis
of each significant medication error, focusing on how the
error occurred (Morris, 1999). The emphasis is on the error,
not the individual who made the error. This strategy is
based on the understanding that blaming an individual for
an error does not take into account the multiple causative
factors involved, nor does it promote an understanding of
how to prevent such errors in the future.
Other
systems approaches to reducing medication errors include
the requirement in most institutions that all medication
orders be entered in the computer by the prescriber, thus
eliminating the confusion caused by an illegible or unclear
handwritten order. When verbal medication errors are taken
by nurses from physicians, individuals are directed to say
numbers as pilots do, "one-five" for 15 to avoid
confusion with 50. Nurses and doctors are also directed
not to use trailing zeros. Two would be written as 2 rather
than 2.0 to avoid confusing 2.0 with 20.
One
of the leading proponents of system redesign, Dr. Leape
has called for safer systems to enhance the efforts of nurses
and other practitioners in reducing errors (Leape, 1995).
With safer systems combined with policies and procedures
that address the ordering, preparing, dispensing, administering
and monitoring of medications, organizations can expect
a reduction in the number of medication errors occurring
in healthcare.
References
Bates
DW, Cullen DJ, Laird N, Peterson LA, Small SD, Servi D,
Laffel G, Sweitzer BJ, Shea BF, Hallisey R et al. (1995).
Incidence of adverse events and potential adverse events.
Journal of the American Medical Association, 274(1);
29-34.
Edes
TE & Sunderrajan EV. (1985). Heparin-induced hyperkalemia.
Archives of Internal Medicine, 145; 1070-1072.
Leape
LL. (1995). Systems analysis of adverse drug events. Journal
of the American Medical Association, 274(1); 35-43.
Morris
MR. (1999). Preventing med errors. Registered Nurse,
62(9); 69-72.
Pataleo
NP & Talan M. (2000). Applying the performance improvement
team concept to the medication order process. Journal
for Healthcare Quality, 20(2), 30-35.
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