Reducing Medical Errors

AGENCIES CONCERNED WITH SAFER MEDICAL CARE:

• ARHQ
  • U.S. Agency for Healthcare Research and Quality (AHRQ) .
  • WebM&M: Morbidity & Mortality Rounds .
  • Health Care: Medical Errors & Patient Safety.
• Institute of Medicine - (National Academy of Sciences) - The sponsors of Dr. Leape's 1991 report on medical errors discusses approaches to safer health care.
• Risk Management Foundation
• The Institute For Safe Medication Practices (ISMP) .
• Joint Commission on Accreditation of Healthcare Organizations .
• United States Pharmacopeial Convention Inc. U.SP. has been setting standards for drugs since 1820.
• MedWatch at U.S. Food & Drug Administration

ARTICLES:

DW Bates, M.D., and A A Gawande, M.D., M.P.H.
New Engl J Med 2003 June 19 348(25):2526-34

This important article identifies areas in which readily availble technology can reduce errors by as much as 80%. No less important are the 59 references discussing ways in which technology can reduce medical errors.

K.G.M. Volpp, M.D., Ph.D. D. Grande, M.D.
NEJM 348(9):851-855 February 27, 2003

The authors identify 8 areas of concern and discuss changes that are necessary to avoid needess patient morbidity and morality.

New York Times June 28, 2002

Kaiser Permanente radiologist improves accuracy by firing doctors who have high error rates
- the result was 1/3 fewer cancers missed.

Telegraph Herald (Dubuque, IA); March 2, 2001, Pg. a2

U.S. scientists have developed highly effective treatments for many diseases but too many Americans get inadequate, outdated or even unsafe therapy instead because the nation's health-care system is a tangled maze, the Institute of Medicine said in a scathing report Thursday.

Prepared Statement of Lucian L. Leape, M.D. Harvard School of Public Health Subject Before the Senate Committee on Health, Education, Labor and Pensions; May 24, 2001

AORN Journal April 1, 2002 ; JCAHO call for Safety

The Baltimore Sun December 22, 2001; Baltimore VA reports progress in decreasing medical errors.

The Boston Herald March 30, 2001

Every hospital has doctors whose performance is a concern, said Dr. Lucian L. Leape, professor at the Harvard School of Public Health. We do have problem doctors. Everybody has witnessed it. But everybody insists it is someone else's problem. It's a major issue and hospitals have to take the primary responsibility.

PR Newswire January 17, 2002 , Thursday

Leapfrog Group Unveils First Results of Unique Survey: Initial Focus on Six Regions including Atlanta, California, East Tennessee, Minnesota, St Louis, and Seattle-Tacoma-Everett http://www.leapfroggroup.org

Chicago Tribune, February 2, 2000, Pg. 7

An expert on medical mistakes, which kill as many as 98,000 Americans every year, called last week for limiting the notoriously long hours medical personnel work.

Consultant; 41(6) p. 766 May 1, 2001

Sound-alike Drugs; Lack of Drug Knowledge; Dose Calculation Errors; Decimal Point Misplacement; Wrong Dosage Form; Wrong Frequency; Use of Abbreviations; Drug Interactions; Renal Insufficiency; Incomplete Patient History http://www.usp.org/reporting/review/qr66.pdf .1000 name pairs that have been confused on prescriptions have been identified

Leape LL, et al. JAMA. 1999; 282(3):267-270.

In group with Senior pharmacist participating in ICU rounds, The rate of preventable ordering Adverse Drug Events decreased by 66% from 10.4 per 1000 patient-days before the intervention to 3.5 after the intervention.

Modern Healthcare; April 22, 2002, Monday

Part of the initial step in making progress is understanding that there's a problem. Now we know there's a problem.

AHRQ Publication No. 00-PO58 April, 2000

Nat'l Academy Press, Crossing the Quality Chasm: (2001).

Nursing Economics January 1, 2002, http://www.premierinc.com/

Washington Post, December 12, 2001

The Boston Herald October 30, 2001; NEWS; Pg. 016

The three-year project will seek more information about how errors occur and about how patients, doctors, hospital officials and others can make the system safer.

Journal of Law, Medicine & Ethics September 22, 2001; Pg. 369

Comments by Kenneth Shine, M.D. President of the Institue of Medicine

The New York Times June 18, 2002

The patient had been on the operating table for an hour. Doctors had made an incision in her groin, punctured an artery, threaded in a tube and snaked it up into her heart. Now they were stimulating her heart electrically, to test for abnormal rhythms.

The phone rang: it was a doctor from another department. What, he asked, were they doing with his patient? There was nothing wrong with her heart.

Patient Care June 15, 2001; Pg. 95

Links - Medical Errors and Preventing Medical Errors

Preventing Medical Errors — Abstract from Nursing Learning Network course

Home Study Educators — Preventing Medical Errors (50 Page PDF with annotations)

New York Medical College Family Practice Residency — Guide for preventing medical errors (90 page PDF - LONG DOWNLOAD!)

1999 Insitiute of Medicine report — How the IOM concluded that from 44,000 to 98,000 die annually from medical errors

Media Citations to the IOM Report