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Medical Errors:

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Handheld Computers for residents (5 min) Error Survey ... results will be reported, and will gladly be shared with the group when results ... – PowerPoint PPT presentation

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Title: Medical Errors:


1
Medical Errors _at_!IT happens
  • Tom Houston, MD MPH
  • Division of General Internal Medicine

2
Overview
  • Brief survey about errors (5-10 min)
  • Discuss a case (5-10 min)
  • To Err is Human (20 min)
  • Handheld Computers for residents (5 min)

3
Error Survey
  • This survey will allow us to better understand
    how resident physicians, such as yourself,
    perceive the issue of medical errors. An
    important ingredient in the promotion of patient
    safety is high quality continued education and
    effective health policies. Results from this
    study will allow policy makers and educators to
    design and execute solutions in a manner that
    incorporates the physician's perspective.
  • Kindly take about 5-10 minutes to complete this
    questionnaire. Please remember that while your
    participation in the survey or any individual
    question is voluntary. Also keep in mind that
    your responses will be kept anonymous and
    strictly confidential. Only aggregate results
    will be reported, and will gladly be shared with
    the group when results from other residents
    around the country are tabulated.

4
A case of error
  • Dr. Davis
  • Dr. Brown
  • Dr. Shannon

5
Frail, 93 year-old female
  • A frail, 93 year-old female was living with her
    family. She had dementia and at baseline was
    oriented to person and place. She required
    assistance with most activities of daily life.
    Her outpatient medical record also noted
    diagnoses of chronic renal insufficiency and
    hypertension.

6
Hospitalized
  • She had a decline over three to four days with
    worsening lethargy and was admitted to a private
    hospital in Birmingham with a diagnosis of
    urosepsis. On admission, her creatinine was 1.8.
    Her outpatient medical records were not available
    to the medical team. One night, the patient got
    out of bed, fell and suffered a hip fracture. The
    hospital had a nursing staff shortage on the
    medicine floor.

7
The end
  • She was not felt to be a candidate for hip
    repair. With the resolution of her urosepsis, her
    mental status had improved, but the narcotics for
    hip pain made her very drowsy. The attending
    physician discharged the patient on Celebrex for
    pain. She did poorly at home and was brought to
    UAB for further care. She was noted to be in
    acute renal failure with a creatinine of 4.9
    Soon after admission, she died.

8
Discussion
9
Objectives
  • Research is still somewhat fuzzy
  • Major push to study patient safety
  • Bad things happen, some can be prevented
  • Human error does not equal blame
  • System problems

10
Errors Happen
11
Definitions
12
Types of Errors
  • Diagnostic
  • Error or delay in diagnosis Failure to use
    appropriate tests Use of outmoded tests Failure
    to act on diagnostic tests
  • Treatment
  • Procedure error Dosage or method Avoidable
    delay Contraindicated care
  • Preventive

13
To Err is Human
  • Institute of Medicine report
  • Published in 2000
  • Summarizes medical literature
  • Looks to other industries
  • Provides recommendations for reducing problems of
    medical errors

14
Magnitude of the Problem
Number of Deaths
15
Recommendations of IOM
  • Research agenda for patient safety
  • Reporting system for errors
  • (voluntary and mandatory)
  • Create new safety systems
  • Develop curricula on patient safety

16
Impact of Report
  • Government-wide study of report
  • AHRQ 50 million dollars for studies related to
    patient safety
  • Research controversy

17
Research
  • It all still seems a little FUZZY to me! -
    Robert Centor, MD

18
Studies of Medical Errors
  • New York Hospitals
  • Colorado/Utah hospitals
  • Retrospective chart review using standard chart
    abstraction instrument
  • Representative sample of hospitals
  • Randomly selected patients

19
Comparison of Studies
20
Methodologic Issues
  • Observational studies
  • Retrospective
  • Differences between the studies
  • Temporal changes (1984 ? 1992)
  • Patient differences
  • Methodologic differences

21
The Controversy
  • Errors are exaggerated
  • Errors are not exaggerated

22
Errors are Exaggerated
  • Observational studies
  • Generalizability/selection bias
  • Baseline risk argument
  • No comparison group
  • Hindsight bias
  • McDonald CM Weiner M Hui SL. JAMA 284(1).

23
Errors are not Exaggerated
  • Medical records may understimate
  • Not very sick/deaths not inevitable
  • Only certain errors studied
  • Focused only on inpatient errors
  • Prospective and controlled studies have reported
    higher rates of errors
  • Leape LL. JAMA 284(1).

24
System Problems / Human Errors
25
Why Do Errors Occur?
  • Errors are due to the convergence of multiple
    factors
  • Human factors/ System factors
  • Systems approach

26
Systems Solutions
  • Standardization
  • Protocols
  • Electronic order entry
  • Reminder systems
  • Decision support systems

27
Leapfrog
  • 90 public and private institutions
  • National Healthcare Purchasing Institute
  • 28 million healthcare consumer

28
Conclusions
  • Errors occur, some can be prevented
  • Research is still somewhat fuzzy
  • Human error does not equal blame
  • System problems
  • Major push to study patient safety

29
Handheld Decision Support Study
  • Eta Berner, Ed.D.
  • Tom Houston, MD
  • Gustavo R. Heudebert, MD
  • Jeroan Allison, MD
  • John I. Kennedy, MD
  • W. Winn Chatham, MD

30
Handheld DSS
  • Barriers
  • Usage
  • Impact

31
Handheld DSS
  • State of the art Handheld
  • Commercially developed software by major DSS
    manufacturer
  • You can customize

32
Go Wake Forest
33
Adverse Events
  • An injury caused by medical management rather
    than the underlying condition of the patient
  • Preventable AE attributable to error
  • Negligent AE care provided failed to meet the
    standard of care reasonably expected of an
    average physician.

34
Medical Error
  • The failure of a planned action to be completed
    as intended or the use of a wrong plan to achieve
    an aim.
  • Errors in planning
  • Errors in execution

35
Cost of Errors
  • Reviewed 459 AEs (Colorado/Utah) study
  • Healthcare costs associated with preventable
    errors 159 million
  • Extrapolated to US 17 billion dollars
  • Higher than HIV/AIDS

36
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