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1. Medical Errors: The Scope of the Problem

An Epidemic of Errors

Medical Errors: The Scope of the Problem

Fact sheet, Publication No. AHRQ 00-P037. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/errback.htm

An Epidemic of Errors: An Overview

The November 1999 report of the Institute of Medicine (IOM), entitled To Err Is Human: Building A Safer Health System, focused a great deal of attention on the issue of medical errors and patient safety. The report indicated that as many as 44,000 to 98,000 people die in hospitals each year as the result of medical errors.

Even using the lower estimate, this would make medical errors the eighth leading cause of death in this country—higher than motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516). About 7,000 people per year are estimated to die from medication errors alone—about 16 percent more deaths than the number attributable to work-related injuries.

The President ordered the Quality Interagency Coordination Task Force to make recommendations on improving health care quality and protecting patient safety in response to the IOM report. The Report to the President on Medical Errors was issued in February 2000. For more information on medical errors, select http://www.ahrq.gov/qual/errorsix.htm.

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[1.1]  Where Errors Occur

Errors occur not only in hospitals but in other health care settings, such as physicians’ offices, nursing homes, pharmacies, urgent care centers, and care delivered in the home. Unfortunately, very little data exist on the extent of the problem outside of hospitals. The IOM report indicated, however, that many errors are likely to occur outside the hospital. For example, in a recent investigation of pharmacists, the Massachusetts State Board of Registration in Pharmacy estimated that 2.4 million prescriptions are filled improperly each year in the State.

[1.2] Costs

Medical errors carry a high financial cost. The IOM report estimates that medical errors cost the Nation approximately $37.6 billion each year; about $17 billion of those costs are associated with preventable errors. About half of the expenditures for preventable medical errors are for direct health care costs.

Not a New Issue

The serious problem of medical errors is not new, but in the past, the problem has not gotten the attention it deserved. A body of research describing the problem of medical errors began to emerge in the early 1990s with landmark research conducted by Lucian Leape, M.D., and David Bates, M.D., and supported by the Agency for Health Care Policy and Research, now the Agency for Healthcare Research and Quality (AHRQ).

The final report of the President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry, released in 1998, identified medical errors as one of the four major challenges facing the Nation in improving health care quality. Based on the recommendations of that report, President Clinton directed the establishment of the Quality Interagency Coordination Task Force (QuIC) to coordinate quality improvement activities in Federal health care programs.

The QuIC includes: the Departments of Health and Human Services, Labor, Veterans Affairs, Commerce, and Defense; the Coast Guard; the Bureau of Prisons; and the Office of Personnel Management.

[1.3]  Public Fears

While there has been no unified effort to address the problem of medical errors and patient safety, awareness of the issue has been growing. Americans have a very real fear of medical errors. According to a national poll conducted by the National Patient Safety Foundation:

• Forty-two percent of respondents had been affected by a medical error, either personally or through a friend or relative.
• Thirty-two percent of the respondents indicated that the error had a permanent negative effect on the patient’s health.

Overall, the respondents to this survey thought the health care system was “moderately safe” (rated a 4.9 on a 1 to 7 scale, where 1 is not safe at all and 7 is very safe).

Another survey, conducted by the American Society of Health-System Pharmacists, found that Americans are “very concerned” about:

• Being given the wrong medicine (61 percent).
• Being given two or more medicines that interact in a negative way (58 percent).
• Complications from a medical procedure (56 percent).

Most people believe that medical errors are the result of the failures of individual providers. When asked in a survey about possible solutions to medical errors:

• Seventy-five percent of respondents thought it would be most effective to “keep health professionals with bad track records from providing care.”
• Sixty-nine percent thought the problem could be solved through “better training of health professionals.”

This fear of medical errors was borne out by the interest and attention that the IOM report generated. According to a survey by the Kaiser Family Foundation, 51 percent of Americans followed closely the release of the IOM report on medical errors.

[1.4] It’s a Systems Problem

The IOM emphasized that most of the medical errors are systems related and not attributable to individual negligence or misconduct. The key to reducing medical errors is to focus on improving the systems of delivering care and not to blame individuals. Health care professionals are simply human and, like everyone else, they make mistakes. But research has shown that system improvements can reduce the error rates and improve the quality of health care:

• A 1999 study indicated that including a pharmacist on medical rounds reduced the errors related to medication ordering by 66 percent, from 10.4 per 1,000 patient days to 3.5 per 1,000 patient days.
• The specialty of anesthesia has reduced its error rate by nearly sevenfold, from 25 to 50 per million to 5.4 per million, by using standardized guidelines and protocols, standardizing equipment, etc.
• One hospital in the Department of Veterans Affairs uses hand-held, wireless computer technology and bar-coding, which has cut overall hospital medication error rates by 70 percent. This system is soon to be implemented in all VA hospitals.

[1.5] Types of Errors

The IOM defines medical error as “the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim.” An adverse event is defined as “an injury caused by medical management rather than by the underlying disease or condition of the patient.” Some adverse events are not preventable and they reflect the risk associated with treatment, such as a life-threatening allergic reaction to a drug when the patient had no known allergies to it. However, the patient who receives an antibiotic to which he or she is known to be allergic, goes into anaphylactic shock, and dies, represents a preventable adverse event.

Most people believe that medical errors usually involve drugs, such as a patient getting the wrong prescription or dosage, or mishandled surgeries, such as amputation of the wrong limb. However, there are many other types of medical errors, including:

• Diagnostic error, such as misdiagnosis leading to an incorrect choice of therapy, failure to use an indicated diagnostic test, misinterpretation of test results, and failure to act on abnormal results.
• Equipment failure, such as defibrillators with dead batteries or intravenous pumps whose valves are easily dislodged or bumped, causing increased doses of medication over too short a period.
• Infections, such as nosocomial and post-surgical wound infections.
• Blood transfusion-related injuries, such as giving a patient the blood of the incorrect type.
• Misinterpretation of other medical orders, such as failing to give a patient a salt-free meal, as ordered by a physician.

[1.6] Preventing Errors

Research clearly shows that the majority of medical errors can be prevented:

• One of the landmark studies on medical errors indicated 70 percent of adverse events found in a review of 1,133 medical records were preventable; 6 percent were potentially preventable; and 24 percent were not preventable.
• A study released last year, based on a chart review of 15,000 medical records in Colorado and Utah, found that 54 percent of surgical errors were preventable.

Other potential system improvements include:

• Use of information technology, such as hand-held bedside computers, to eliminate reliance on handwriting for ordering medications and other treatment needs.
• Avoidance of similar-sounding and look-alike names and packages of medication.
• Standardization of treatment policies and protocols to avoid confusion and reliance on memory, which is known to be fallible and responsible for many errors.

Source: Medical Errors: The Scope of the Problem. Fact sheet, Publication No. AHRQ 00-P037. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/errback.htm

2. Reducing Errors in Health Care

Translating Research Into Practice: Reducing Errors in Health Care

Agency for Healthcare Research and Quality, April 2000

Medical errors are responsible for injury in as many as 1 out of every 25 hospital patients; an estimated 48,000-98,000 patients die from medical errors each year. Errors in health care have been estimated to cost more than $5 million per year in a large teaching hospital, and preventable health care-related cost the economy from $17 to $29 billion each year.

Agency for Healthcare Research and Quality (AHRQ) research has shown that medical errors may result most frequently from systems errors—organization of health care delivery and how resources are provided in the delivery system.

Patients at Risk

Medical errors may result in:

• A patient inadvertently given the wrong medicine.
• A clinician misreading the results of a test.
• An elderly woman with ambiguous symptoms (shortness of breath, abdominal pain, and dizziness) whose heart attack is not diagnosed by emergency room staff.

Errors like these are responsible for preventable injury in as many as 1 out of every 25 hospital patients.

Errors in health care have been estimated to cost more than $5 million per year in a large teaching hospital. According to a recent report by the Institute of Medicine (IOM)³, preventable health care-related injuries cost the economy from $17 to $29 billion annually, of which half are health care costs.

The IOM report estimates that 44,000 to 98,000 people each year die from medical errors. Even the lower estimate is higher than the annual mortality from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516), thus making medical errors the eighth leading cause of death in the United States.

These and other findings of the IOM report are based on research sponsored by a variety of organizations, including the Agency for Healthcare Research and Quality (AHRQ).

For example, a study by AHRQ found that just one type of error—preventable adverse drug events—caused one out of five injuries or deaths per year to patients in the hospitals that were studied.

How Errors Occur

Errors can occur at any point in the health care delivery system, AHRQ-supported research has revealed.

MEDICATION ERRORS

These are preventable mistakes in prescribing and delivering medication to patients, such as prescribing two or more drugs whose interaction is known to produce side effects or prescribing a drug to which the patient is known to be allergic.

Research by AHRQ-supported investigators is helping to characterize these errors (called preventable adverse drug events, or ADEs) and suggest how to prevent them.

• In a study of inpatient care in two tertiary care hospitals, errors in ordering and administering medicines accounted for 56 and 34 percent, respectively, of preventable adverse drug events.
• Findings from a second study showed that dosage errors, in particular, were primarily due to the physician’s lack of knowledge about the drug or about the patient for whom it was prescribed.
• An attempt to identify risk factors for preventable adverse drug reactions among patients admitted to medical and surgical units at two large hospitals⁷ found few such factors, which suggested to the researchers that a focus on improving medication systems would prove more effective.

SURGICAL ERRORS

In contrast to ADEs, surgical adverse events (1 in 50 admissions in Colorado and Utah hospitals during 1992), accounted for two-thirds of all adverse events and 1 of 8 hospital deaths in a recent retrospective study of these institutions by an AHRQ fellow.

DIAGNOSTIC INACCURACIES

Incorrect diagnoses may lead to incorrect and ineffective treatment or unnecessary testing, which is costly and sometimes invasive. Also, inexperience with a technically difficult diagnostic procedure can affect the accuracy of the results. Here, too, AHRQ-funded researchers have made major contributions.

• One study showed that physicians who performed 100 or more colposcopies (a test used to follow up abnormal Pap smears) a year had more accurate findings than physicians who performed the procedure less often.
• Another study demonstrated that measuring blood pressure with the most commonly used type of equipment often gives incorrect readings that may lead to mismanagement of hypertension.

SYSTEM FAILURES

Although errors in medication, surgery, and diagnosis are the easiest to detect, medical errors may result more frequently from the organization of health care delivery and the way that resources are provided to the delivery system. Research by AHRQ-supported scientists is helping to identify the systemic factors contributing to preventable adverse events.

• Investigators in a major stud discovered that failures at the system level were the real culprits in over three-fourths of adverse drug events.
• Failures in disseminating pharmaceutical information, in checking drug doses and patient identities, and in making patient information available are system errors that accounted for adverse drug events in over half of the hospitals studied.
• One system-level factor, staffing levels of nurses (adjusted for hospital characteristics), was found in a study to influence the incidence of adverse events following major surgery, such as urinary tract infections, pneumonia, thrombosis, and pulmonary compromise.

This research on systemic problems leads investigators to conclude that any effort to reduce medical errors in an organization requires changes to the system design, including possible reorganization of resources by top-level management.

Source: http://archive.ahrq.gov/qual/errors.htm Reducing Errors in Health Care: Translating Research into Practice. AHRQ Publication No. 00-PO58, April 2000

3. 30 Safe Practices for Better Health Care

Source: 30 Safe Practices for Better Health Care: Fact Sheet. March 2005. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/research/findings/factsheets/errors-safety/30safe/30-safe-practices.html

4. Safe Practices for Better Healthcare

A Consensus Report

National Quality Forum

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Heightened attention focused on medical errors has sparked growing interest in the use of healthcare practices that reduce the risk of harm resulting from the processes, systems, or environments of care—”safe practices.” This summary describes 30 practices that should be universally used in applicable clinical care settings to reduce the risk of harm to patients from adverse healthcare events.

This set of safe practices has been carefully reviewed and endorsed by a diverse group of stakeholders pursuant to the National Quality Forum’s formal Consensus Development Process.

Used with permission from the National Quality Forum,© 2003. Adapted from the original Executive Summary at: http://www.qualityforum.org/txsafeexecsumm+order6-8-03PUBLIC.pdf

Select to download print version (PDF file, 495 KB). PDF Help.

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Summary

Adverse healthcare events are a leading cause of death and injury in the United States—even though in many cases evidence-based methods are available that can prevent these deaths and injuries from occurring. Increasingly, practices that reduce the risk of harm from the processes, systems, or environments of healthcare—i.e., “safe practices”—are being deployed. The lack of standardization of these practices, however, may mitigate some of their benefits.

This National Quality Forum (NQF) report details 30 healthcare practices that should be universally utilized in applicable clinical care settings to reduce the risk of harm to patients. Although this set of safe practices is not intended to capture all activities that might reduce adverse healthcare events, it has been carefully reviewed and endorsed by a diverse group of stakeholders. Specifically, the set focuses on high-priority practices that:

• have strong evidence that they are effective in reducing the likelihood of harming a patient;
• are generalizable (i.e., they may be applied in multiple clinical care settings and/or multiple types of patients);
• are likely to have a significant benefit to patient safety if fully implemented; and
• have knowledge about them that is usable by consumers, purchasers, providers, and researchers.

Practices were derived from a report by the Agency for Healthcare Research and Quality’s University of California San Francisco-Stanford University Evidence-Based Practice Center; the Leapfrog Group’s three safety “leaps”; the NQF project Steering Committee; NQF Members; and health professional specialty societies and other organizations responding to NQF’s open call for suggested safe practices. All practices were evaluated based on the criteria of specificity (threshold criterion), benefit, evidence of effectiveness, generalizability, and readiness.

The practices are organized in five broad categories for improving patient safety:

• creating a culture of safety;
• matching healthcare needs with service delivery capability;
• facilitating information transfer and clear communication;
• adopting safe practices in specific clinical care settings or for specific processes of care; and
• increasing safe medication use.

By intent, the safe practices are not prioritized within or across categories because all are viewed as important in improving patient safety. Additionally, no objective, evidence-based method of prioritizing the practices could be identified that would equitably apply across the current heterogeneous universe of healthcare facilities. For any given healthcare provider, the choice of practices that will have top priority will depend on the individual provider’s circumstances, including what practices already have been implemented, availability of resources, environmental constraints, and patient mix.

Also identified in the report are 27 practices that should receive high priority for additional research. Finally, the report recommends specific actions in the following three areas: dissemination and implementation of the practices; measuring their implementation; and updating and improving the set of practices.

NQF-Endorsed Set of Safe Practices

1. Create a healthcare culture of safety.
2. For designated high-risk, elective surgical procedures or other specified care, patients should be clearly informed of the likely reduced risk of an adverse outcome at treatment facilities that have demonstrated superior outcomes and should be referred to such facilities in accordance with the patient’s stated preference.
3. Specify an explicit protocol to be used to ensure an adequate level of nursing based on the institution’s usual patient mix and the experience and training of its nursing staff.
4. All patients in general intensive care units (both adult and pediatric) should be managed by physicians having specific training and certification in critical care medicine (“critical care certified”).
5. Pharmacists should actively participate in the medication-use process, including, at a minimum, being available for consultation with prescribers on medication ordering, interpretation and review of medication orders, preparation of medications, dispensing of medications, and administration and monitoring of medications.
6. Verbal orders should be recorded whenever possible and immediately read back to the prescriber—i.e., a healthcare provider receiving a verbal order should read or repeat back the information that the prescriber conveys in order to verify the accuracy of what was heard.
7. Use only standardized abbreviations and dose designations.
8. Patient care summaries or other similar records should not be prepared from memory.
9. Ensure that care information, especially changes in orders and new diagnostic information, is transmitted in a timely and clearly understandable form to all of the patient’s current healthcare providers who need that information to provide care.
10. Ask each patient or legal surrogate to recount what he or she has been told during the informed consent discussion.
11. Ensure that written documentation of the patient’s preference for life-sustaining treatments is prominently displayed in his or her chart.
12. Implement a computerized prescriber order entry system.
13. Implement a standardized protocol to prevent the mislabeling of radiographs.
14. Implement standardized protocols to prevent the occurrence of wrong-site procedures or wrong-patient procedures.
15. Evaluate each patient undergoing elective surgery for risk of an acute ischemic cardiac event during surgery, and provide prophylactic treatment of high-risk patients with beta blockers.
16. Evaluate each patient upon admission, and regularly thereafter, for the risk of developing pressure ulcers. This evaluation should be repeated at regular intervals during care. Clinically appropriate preventive methods should be implemented consequent to the evaluation.
17. Evaluate each patient upon admission, and regularly thereafter, for the risk of developing deep vein thrombosis (DVT)/venous thromboembolism (VTE). Utilize clinically appropriate methods to prevent DVT/VTE.
18. Utilize dedicated anti-thrombotic (anti-coagulation) services that facilitate coordinated care management.
19. Upon admission, and regularly thereafter, evaluate each patient for the risk of aspiration.
20. Adhere to effective methods of preventing central venous catheter-associated blood stream infections.
21. Evaluate each pre-operative patient in light of his or her planned surgical procedure for the risk of surgical site infection, and implement appropriate antibiotic prophylaxis and other preventive measures based on that evaluation.
22. Utilize validated protocols to evaluate patients who are at risk for contrast media-induced renal failure, and utilize a clinically appropriate method for reducing risk of renal injury based on the patient’s kidney function evaluation.
23. Evaluate each patient upon admission, and regularly thereafter, for risk of malnutrition. Employ clinically appropriate strategies to prevent malnutrition.
24. Whenever a pneumatic tourniquet is used, evaluate the patient for the risk of an ischemic and/or thrombotic complication, and utilize appropriate prophylactic measures.
25. Decontaminate hands with either a hygienic hand rub or by washing with a disinfectant soap prior to and after direct contact with the patient or objects immediately around the patient.
26. Vaccinate healthcare workers against influenza to protect both them and patients from influenza.
27. Keep workspaces where medications are prepared clean, orderly, well lit, and free of clutter, distraction, and noise.
28. Standardize the methods for labeling, packaging, and storing medications.
29. Identify all “high alert” drugs (e.g., intravenous adrenergic agonists and antagonists, chemotherapy agents, anticoagulants and anti-thrombotics, concentrated parenteral electrolytes, general anesthetics, neuromuscular blockers, insulin and oral hypoglycemics, narcotics and opiates).
30. Dispense medications in unit-dose or, when appropriate, unit-of-use form, whenever possible.

Source: http://www.ahrq.gov/qual/nqfpract.htm

5. Resources for Continuous Quality Control

Five Steps to Safer Health Care
20 Tips to Help Prevent Medical Errors: Patient Fact Sheet
20 Tips to Help Prevent Medical Errors in Children
AHRQ’s Efforts to Prevent and Reduce Health Care-Associated Infections
It’s Your Health: Use Your Medications Safely
Ways You Can Help Your Family Prevent Medical Errors!
Your Guide to Preventing and Treating Blood Clots
Advancing Patient Safety: A Decade of Evidence, Design, and Implementation
Ending Health Care-Associated Infections
To Err is Human: Building a Safer Health System
Health Care-Associated Infections: Tools & Resources
Improving Patient Safety Through Simulation Research
Medical Errors: The Scope of the Problem
Methodological Shortcomings and Estimates of Adverse Events: Technical Review
National Survey on Consumer Experiences With Patient Safety and Quality
Patient Safety: Achieving a New Standard for Care
Patient Safety and Health Information Technology E-newsletter Archives
Patient Safety Research Highlights: Program Brief
Reducing Medical Errors in Health Care: Fact Sheet
Safe Practices for Better Healthcare: Summary
Web Chat Transcript: Patient Safety Research
Web M&M: Fact Sheet

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