1.Medical Mistakes AN APPROACH FOR TRACKING AND REDUCING HOSPITAL ERRORSBy Terry Coulon HSM 542S

2. HIGHLIGHTSS Introduction to common Hospital and medication Errors S IOMs impact on tracking and reducing hospital errors S The Pros and Cons of the IOMs Recommendations S An alternative plan for reducing and tracking hospitalerrors S Alternative plans impact on hospital errors and itssustainability 3. Whats a Medical/Medication Error S A Medical Error is a preventable adverse effect ofcare, whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome behavior, infection, or other ailment. S A Medication Error is any incorrect or wrongful administrationof a medication, such as a mistake in dosage or route of administration, failure to prescribe or administer the correct drug or formulation for a particular disease or condition, use of outdated drugs, failure to observe the correct time for administration of the drug, or lack of awareness of adverse effects of certain drug combinations 4. Common medical and medication Errors SCommon medical errors that takes place within todays hospitals are:SCommon medication errors that takes place within todays hospitals are:SDiagnostic errorsSOrdering errorsSTreatment and prevention errorsSTranscribing errorsSMiscellaneous errors (i.e. communication, equipment and systemic failures).SDispensing errorsSAdministrating errorsSMonitoring errors 5. IOM TO THE RESCUE ???S 6. The IOMs ContributionS The Institute of Medicine (IOM) is an independent, nonprofitorganization that works outside of government to provide unbiased and authoritative advice to decision makers and the public. S In 1999, IOM published a research report titled To Err isHuman: Building a Safer Health System S The report was used to help formulate four specificrecommendations for tracking and diminishing errors within a hospital setting. 7. Ideas for addressing hospital Errors S1st RECCOMENDATIONS2ND RECCOMENDATIONcreating a center for patient safety within the agency for healthcare Research and Quality. S 3RD RECCOMENDATIONSThe establishment of mandatory and voluntary reporting systems.S4th RECCOMENDATIONSSCreating safety systems inside healthcare organizations through safe practice implementations at the delivery level of care.SRaise standards for improvement in safety through the actions and oversight of organizations, group purchasers and professional groups 8. Did the IOM Succeed?S Five years since these recommendations were entertained bythe U.S. Congress for proposed implementation at the federal level, the rate of medical and medication errors has remained relatively high S Extensive research performed in 2004 year suggested thatmedical errors still remained high, including several issues regarding substandard patient care with errors S The IOM failed to fulfill its expectations of a 50% reduction inmedical/medication errors based upon the institute's recommendations. 9. Why did the IOM Fail? PROS SThe creation of center for patient safety within the agency was realized.SIOMs 4th recommendation has sparked the evolution of technology advanced health safety systems (I.E. Health IT systems).CONS SCompliance with mandatory and voluntary reporting systems has been inconsistent due to physician's fears of malpractice lawsuits and financial penalties.SBusiness groups such as Leapfrog have designed tools that inaccurately capture hospital error costs.SNewly developed Health safety IT systems have added to medical errors within many hospitals. 10. Hospital Errors are still a problem Medical Error Mortality rate of 2004Medical Error Mortality rate of 2012S195,000 Americans died as a result of preventable errors .S134,000 Americans died as a result of preventable errors.SOverall costs attributable to hospital errors was around $25 billion.SOverall costs attributable to hospital errors was $19.5 billion.SBed sores, failure to rescue, and post-operative respiratory failure were the most common errors.SPatient misidentifications, medical equipment misuse and misdiagnosis were the most common errors. 11. Numbers Dont Lie 2012 Incident report12% 63% 25%63%clinical process staff behavior medications 12. IS THERE AN ALTERNATIVE??? To reduce the amount of hospital errors, a more comprehensive approach is needed ~ FDAS 13. All Hands on Deck SThe All Hands on Deck Patient Safety plan is a four part collaborative plan involving the IOM, state legislatures, the Food and Drug Administration and the Department of Health and Human Services. The plan is as follows:SA team of adverse medical event researchers and analysts, affiliated with the IOM, will be acquiring all relevant medical and medication error data (i.e Inpatient, Outpatient and Ambulatory).SCalifornias Voluntary reporting bill will be presented to all other states legislature in an effort to implement this version of the bill to increase physician error reporting.SHealth business groups with proposed calculating cost tools for hospital errors will go through a Health business oversight and regulatory committee as an extension of HHS (Health and Human Services) department.SProposed health IT systems and tools shall go through the risk-based regulatory framework headed by the FDA for approval to ensure its 14. Benefits and Drawbacks BenefitsDrawbacksSSIts a comprehensive effort at the state and federal level to exclusively target and reduce hospital errors.SThe plan doesnt take into account nursing and retirement home errors.SCash Strapped hospital budgets might stop the plans full implementation.SSThe plan hinges on U.S. Congressional approval for complete operation and implementation.The plans costs is a little under a $1 million dollars to operate. It broadens the scope of Health regulatory agencies involving the publics health and well being. 15. Is there a Backup PlanS If Congress rejects All Hands on Deck, a contingency plan for targeting and reducing hospital errors will follow. SThe plan will consist of representatives from the IOM visiting only those hospitals ranked High on the mixed method analysis; where information and training sessions will be held on monthly basis.Ssessions will give patients, physician and other allied health professionals information regarding their hospitals error rates and ways in which these error rates can be improved.SThis plan will be of no charge to the hospital and patients that sign up. 16. All Hands on Deck is Worth It!!! SIn order to effectively impact the rise and cost of medical errors to healthcare, we need a collective effort at the state and federal level.SIf hospitals want to attract more patients, developing a culture of patient safety would be in their best interest towards achieving a quality of care standard that separates them from the competition.SWhile this plan leaves out the reduction of medical errors in nursing homes, a significant majority of medical errors within hospitals are researched, evaluated and regulated under this collaborative effort. 17. QUESTIONS??? 18. References SThe Institute of Medicine. (2013). Medical errors and the Institute of Medicine (IOM). Premier: Transforming Healthcare together. Premier, Inc. https://www.premierinc.com/safety/topics/patient_safety/index_1.jspSAgency for Healthcare Research and Quality (AHRQ) (20130). Voluntary Patient Safety Event Reporting (Incident Reporting). Department of Health and Human Services. http://www.psnet.ahrq.gov/primer.aspx?primerID=13SGideon, G. (2010). Medical Errors tied to patient transfers. White Coat Notes: News from the Boston Area medical community. http://www.boston.com/news/health/blog/2010/10/medical_errors.html?rss_id=Most+PopularSU.S. news and world report. (2010). Cost of medical malpractice tops $55 billion a year in the U.S. USN Health Day. http://health.usnews.com/health-news/managing-your-healthcare/healthcare/articles/2010/09/07/cost-ofmedical-malpractice-tops-55-billion-a-year-in-usSBinder, L. (2013). Leapfrog defends methodology. Modern Healthcare, 43(32), 24.SFoster, N. (2013). Leapfrog tool 'seriously flawed'. Modern Healthcare, 43(31), 16.SConn, J. (2013). Targeting adverse events. Modern Healthcare, 43(27), 10.SLentz, R. (2001). Quiet Report. Modern Physician, 5(9), 2.SBleich, S. (2005). Medical Errors: Five Years After the IOM Report. The commonwealth fund