Medical Errors: An Ongoing Threat to Quality Health Care

Medical Errors: An Ongoing Threat to Quality Health Care Medical Errors: An Ongoing Threat to Quality Health Care Medical errors: adverse events that could have been prevented given current state of medical knowledge Medication error: preventable event causing or leading to inappropriate medication use or patient harm Medication in control of health care professional, patient, or consumer ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS Adverse events: adverse changes in health occurring as a result of treatment. Medical Errors: An Ongoing Threat to Quality Health Care Adverse drug event when medications involved Copyright © 2020 Wolters Kluwer • All Rights Reserved Seminal Research and Medical Errors #1 Benchmark study by Brennan et al. (1991) Study by Thomas et al. (1999) Study by Leape et al. (1991 and 1994) Copyright © 2020 Wolters Kluwer • All Rights Reserved Seminal Research and Medical Errors #2 “To Err Is Human” by the Institute of Medicine (IOM) Death due to medical errors: possibly eighth leading cause of death in 1999 More people die yearly from medical errors than from motor vehicle accidents, breast cancer, or AIDS Examination of types of errors: adverse events with pharmaceutical agents (potentially preventable) Studies confirming IOM figures Confirmation of scope of medical errors in follow-up report by IOM Copyright © 2020 Wolters Kluwer • All Rights Reserved Seminal Research and Medical Errors #3 IOM recommendations: National goal to reduce medical errors by 50% over 5 years Four-pronged approach to reducing medical mistakes nationwide (see Box 14.1) National focus Identification of, and learning from, errors Elevation of standards, expectations for improvement Implementation of safe practices Copyright © 2020 Wolters Kluwer • All Rights Reserved Question #1 Is the following statement true or false? Adverse events result from treatment. Copyright © 2020 Wolters Kluwer • All Rights Reserved Answer to Question #1 True Adverse events are defined as adverse changes in health that occur as a result of treatment. Copyright © 2020 Wolters Kluwer • All Rights Reserved Work to Achieve IOM Goals #1 Quality Interagency Coordination Task Force (1998) Coordination of federal agencies providing health care services Evaluation of IOM recommendations Development of strategies for identifying threats to patient safety, reducing medical errors Final report delivered in February 2000 Copyright © 2020 Wolters Kluwer • All Rights Reserved Work to Achieve IOM Goals #2 National Forum for Health Care Quality Measurement and Reporting (2017) The National Quality Strategy: Aims, Priorities, and Levers Aims Better care Healthy people/Healthy communities Affordable care Copyright © 2020 Wolters Kluwer • All Rights Reserved Work to Achieve IOM Goals #3 The National Quality Strategy: Aims, Priorities, and Levers (see Box 14.3) Six priorities Eight levers Copyright © 2020 Wolters Kluwer • All Rights Reserved Work to Achieve IOM Goals #4 Joint Commission 2017 National Patient Safety Foundation (see Box 14.4) Improve patients correctly Improve staff communication Use medicines safely Use alarms safely Prevent infection Identify patient safety risks Prevent mistakes in surgery Copyright © 2020 Wolters Kluwer • All Rights Reserved Work to Achieve IOM Goals #5 The Joint Commission Comprehensive database of sentinel events Root cause analysis; Sentinel Events Policy Failure mode and effects analysis (FMEA) Copyright © 2020 Wolters Kluwer • All Rights Reserved Work to Achieve IOM Goals #6 Centers for Medicare and Medicaid Services (formerly HCFA) Medicare Quality Initiatives Pay for Performance (quality-based purchasing) Physician Quality Reporting Initiative; became Physician Quality Reporting System with passage of Affordable Care Act of 2011 PQRS transitioned to the Merit-based Incentive Payment System (MIPS) under the Quality Payment Program (Quality Payment Program, 2017) Copyright © 2020 Wolters Kluwer • All Rights Reserved Work to Achieve IOM Goals #7 Centers for Medicare and Medicaid Services (formerly HCFA) Medicare Improvements for Patients and Providers Act (2008) “Never events” (see Box 14.5) Copyright © 2020 Wolters Kluwer • All Rights Reserved Work to Achieve IOM Goals #8 Institute for Healthcare Improvement Highlighting of evidence-based best practices Disciplined research and development processes, prototyping projects Facilitation of further research, adaptation, and adoption of quality improvement strategies Health care report cards Copyright © 2020 Wolters Kluwer • All Rights Reserved Question #2 The National Priorities Partnership evolved out of which of the following? A. Quality Interagency Coordination Task Force B. Centers for Medicare and Medicaid Services C. National Forum for Health Care Quality Measurement and Reporting D. The Floyd D. Spence National Defense Authorization Act of 2001 Copyright © 2020 Wolters Kluwer • All Rights Reserved Answer to Question #2 C The National Priorities Partnership developed from the work of the National Forum for Health Care Quality Measurement and Reporting. Copyright © 2020 Wolters Kluwer • All Rights Reserved Culture of Safety Management Patient safety: one of nation’s most pressing challenges Mandate for every health care organization IOM final recommendation: implementation of safe practices at delivery level Copyright © 2020 Wolters Kluwer • All Rights Reserved Six Sigma Approach Culture of safety management at institutional level Sigma: statistical measurement reflecting product or process performance Higher sigma values = better performance Historically, health care aiming for three-sigma processes instead of six Copyright © 2020 Wolters Kluwer • All Rights Reserved Mandatory Reporting of Errors Mandatory reporting system for medical errors, adverse events at national, state levels As of 2014, at least 26 states requiring hospitals and/or other medical facilities to report serious medical errors Need for increased mandatory reporting at institutional level and by individual providers Possible fear of legal suits or disciplinary measures as barrier for greater disclosure and reporting Copyright © 2020 Wolters Kluwer • All Rights Reserved Legal Liability and Medical Error Reporting Medical liability system + litigious society: potential barriers to systematic efforts to uncover, learn from mistakes Patient Safety Improvement Act (2002) Patient Safety and Quality Improvement Act of 2005 Proposed federal legislation to protect voluntary reporting of ordinary injuries, “near misses” Copyright © 2020 Wolters Kluwer • All Rights Reserved Leapfrog Group Need for implementation of evidence-based standards such as Computerized physician (or prescriber) order entry (CPOE) Leapfrog developed evaluation tool Evidence-based hospital referral (EHR) Intensive-care-unit physician staffing (IPS) Copyright © 2020 Wolters Kluwer • All Rights Reserved Question #3 Is the following statement true or false? A sigma value of three indicates lower performance than a sigma value of five. Copyright © 2020 Wolters Kluwer • All Rights Reserved Answer to Question #3 True A sigma value is a statistical measurement that reflects performance. Thus, the higher the sigma value, the better the performance. Copyright © 2020 Wolters Kluwer • All Rights Reserved Bar Coding Medications Reduction in point-of-care medication errors National drug code number for all prescription, OTC meds used in hospitals Bar coding + CPOE = increased ability to follow “five rights” of medication admin Copyright © 2020 Wolters Kluwer • All Rights Reserved Changing Organizational Culture Quality and Safety Education for Nurses (QSEN) project Knowledge, skills, and attitudes (KSA) necessary to continuously improve the quality and safety of the health care system KSA—better able to identify potential errors and intervene before errors occur Organizational cultures needing to remove blame from individual and focus on how organization can be modified to reduce likelihood of errors “Just culture” or “culture of safety management” Copyright © 2020 Wolters Kluwer • All Rights Reserved Patient Safety Solutions WHO’s Word Alliance for Patient Safety and the Collaborating Centre packaged nine effective solutions called patient safety solutions to reduce health care errors WHO (2017) initiated its third Global Patient Safety Challenge: Medication Without Harm See Box 14.6 Copyright © 2020 Wolters Kluwer • All Rights Reserved Question #4 Which of the following would most likely be most significant in promoting a culture of safety management? A. Mandatory reporting of errors B. Six Sigma approach C. Bar coding meds D. Removal of blame Copyright © 2020 Wolters Kluwer • All Rights Reserved Answer to Question #4 D Although mandatory reporting of errors, a Six Sigma approach, and bar coding meds are important in promoting a culture of safety management, perhaps the most significant change that must occur is that organizational cultures must be created that remove blame from the individual and focus on how the organization can be modified to reduce the likelihood of errors occurring in the future. Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10