Managing Patient Safety - Assignment Example

?Managing Patient safety School Number Managing Patient safety Introduction This paper is concerning a major patient safety issuethat may be a worry in various hospitals and that is medication error. The Institute of Medicine 1999 reported through a report that had defined to the constitution of medical error. According to the IOM, a medical error is referred to as “failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim”. Most of the medical errors are preventable to the extent that inappropriate treatments and unsafe use should be avoided in clinical practice (Patel, 2004). The person on whom the medication/ treatment is administered is harmed, and the person who recommends, performs or prescribes the use of the treatment is at fault (MAC, 2010). Each year more than 98, 000 individuals have fatal outcomes medical errors. The errors may arise as a result of doing the wrong treatment wrong treatment, going ahead with the treatment with insufficient information, or due to inefficient processes. About 10 to 20 % of the medical errors are as a result of errors in prescription of drugs or known as ‘medical errors’ (Patel, 2004). The cost of medical errors are very high and this may result in longer hospital stay, post-treatment complications that require a lot of care, etc (Patel, 2004). A more universal definition of a medication consists of any deviation away from the normal intention, expectation or desirability. There are many other ways of perceiving errors includes psychological ways, sensory events, perceptual occasions, cognitively, motor events, any action in well-managed system, and a negative output in a controlled environment Usually an error is related to an adverse effect and even if errors are not caused, they can still occur. For instance even if a drug is perfectly administered according to doses, indications, contraindications, prevention of interaction, etc, an adverse event can still occur as the (Kopec, 2007). Goldberg 2001 considers that the medical errors may have a serious effect on the system such as increasing the patient stay by a couple of days, which adds on to about a spending of $4600 per patient. Overall, with the total number of medical error cases reported every year, about 2.4 million hospital days would be spend and $9.3 billion. The impact is that patients have longer stay (LOS increased), the return to work is longer (indirect costing), and both these direct and indirect costing is preventable to a large extent (Patel, 2004). Most of the medical errors occur at the rate of 1 per day in a hospital, and they have the chance of causing serious negative outcomes for the hospital. Following the medical error, the aggrieved patient has the right to seek damages and compensation. In the year 2008, Medicare declared it would no longer cover for preventable medical errors in healthcare. Today with the introduction of such measures from the CMS and insurance companies, greater efforts are being laid in reducing medical errors as the hospitals are being held responsible (Patel, 2004). A medical error can be related to various aspects of healthcare including:- On a large scale, it is found that from the physician quarters about 57 to 60% of the errors can be prevented if a computerized ordering system is implemented and can be used appropriately (Maganelli, 2009). Patient Safety According to the AHRQ, patient safety is defined as “...as a discipline in the health care professions that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery...’. Here greater efforts are being placed on trust in the healthcare delivery system (AHRQ, 2008). According to the IOM, patient safety is defined as “...the prevention of harm to patients...” They have placed greater emphasis preventing errors, learning from past errors, building a culture that is safe for the patients including efforts from organisation, professionals and the patients (Mitchell 2008). During practice there is a risk for adverse events, and many of these adverse events occur as a result of medical error especially in association with medications. Pope Quoted “…To err is human… to forgive divine…” As the human mind works through using various cognitive processes and there are no processes of checking with errors, hence, humans are bound to make errors, though the same are reducible by using checklists, reminders and alerts. Though the rate of errors can be reduced, it cannot be prevented mainly because human minds do not work like computers. On the other hand, if humans are blamed for errors, human resources may take up a very defensive position and work towards preventing errors rather than further improving the standard of healthcare. Hence, proper measures are required for efficient management of medical errors (Hawaii University, 2008). Points at which medication Errors can occur The Scenario The hospital has plans to introduce a computerized ordering system (CPOE) within the specialty and super-specialty premises. It has been providing nursing and medical care since the last 30 years, and has been JCAHO Accredited. The overall focus has been on quality improvement, patient safety initiatives and using medical technologies, in spite of several changes of the management and administration. The CPOE implementation would have a significant improvement over patient safety as the manual process of drug ordering and administration would become computerised and there would be better management of all associated risks in the process. Leapfrog Group conducted a study in 2004 to determine the error rates with ordering systems and found that by avoiding handwritten notes and utilising system checks, the patient safety would automatically be improved. They also suggested the that the use of the electronic prescription system can help reduce human errors, as the human factors for error are effectively prevented or reduced (The Leapfrog Group, 2011). In the US healthcare system it is noted that about 60% errors occurs as a result of mistakes made by the physician, and can be potentially avoided using computerised systems with checks of the processes (Maganelli, 2009). In the past, medical errors with drug administration and processes have hit the hospital negatively as there are no system checks of the manual processes, and often unintentional errors do creep in making the system sick (Dixon, 2009). The IOM’s study on CPOE system and healthcare technologies have noted that errors can be significantly reduced if not avoided (Virginia Board of Health Professionals, 2010). Hence many hospitals have sought implementing CPOE systems related to drug ordering and administration. Besides, the efficiency of this system would be improved (Dixon, 2009). Using the system, both the inpatient and the ambulatory settings would be benefited and the paper-based system or in certain circumstances used, the oral-based system would be replaced as far as drug processes are concerned (Maganelli, 2009). Other than this the CPOE system can also be used for various other processes including ordering laboratory tests, procedures, dietary menus, Images, referrals, etc. The system to be implemented need not be advanced, as the organisation can implement the same in modules. It would be vital to have a system that is legible, is evidence-based and offers certain system checks, along with decision-making tools such as to check for drug interactions and contraindications. The CPOE system would also contain various logic modules, rules, formulae, and algorithms, to help check for errors and to avoid the same. Since the individual drug packages would be bar coded, the user would be alerted in case the wrong drugs go to the wrong patient. Besides, since drug-to-drug interactions, medical contraindications and drug dosage calculators would be utilised, as evidence-based tools, they could help reducing medication errors (Dixon, 2009). Error with drugs can occur at various processes including administration, procedure performances, Prescription drafting, Placing orders, Bar-coding and packaging, drug Dispensing, improper use of naming conventions, ineffective distribution & transferring patient education processes and monitoring for drug usage (Patel, 2004 & Maganelli 2004) Through evidences, it can be seen that there are good chances of reducing medical errors in the hospital and also avoid other errors that may arise whilst placing orders. The nurses and the physicians would function more effectively, the quality of care would improve, greater time can be spend with managing more number of patients, evidence-based tools can be utilised for practice, thus improving Evidence-based practice, and in general the hospital would be having multiple benefits from such a schemata. The processes of monitoring and compliance would be improved (MHA, 1999). Studies have shown that the physician errors can be reduced from 50 to 60 %, though it may take at least a decade for various quarters of the hospital to get used to such a system. Currently only 5% of the hospital in the US actually utilise a CPOE system and thus the critics on medication errors is even more serious (Dixon, 2009). System Factors System factors play a vital role in the ordering system so that the errors can be reduced with relation to medication administration. For example, it is important that the systems do not exacerbate or not conduct checks on the human factors with the various processes involved. Nolan 2000 takes the example from an ATM machine that dispenses the cash and would scan the card details. The system design should be such that human factors are taken into consideration and errors are avoided at various processes in the system. For example, an ATM that takes the card of the user may end up in a situation where the user forgets to pick up his card and may end up not taking his card. Hence the system should be designed in such a way that human errors are avoided if not have checks in the system that can overcome human errors. Systems should have logic to identify such errors and to take appropriate steps to alert the users. The system would not only include hardware and software systems, but also the support system and the processes. Hence, these need to be designed so that errors can be minimized and more importantly identified before mistakes can take place (Nolan 2000). In most instances, errors occur when the user is confident of performing the tasks, but makes a mistake of forgetting. In the past, the consequences of such errors have been disastrous, though efforts should be made at reducing the impact of such errors in the future. The aim of the system design in general should include providing checks and supporting the human factors that operate whilst placing orders for drugs and other orders. Systems should work on a fuzzy logic means or from experience with identifying the patterns of errors of the users. They can also work on a system of algorithms or from feedback from other users (Nolan 2000). Automation itself has several errors which are associated, but often the risk of errors from such systems is a fraction and often is not noticeable (say 1 in a million). However, when the systems are coupled with human factors, the error rate is higher, even though it may not appear that the error is caused due to human factors. Information processing is another mean of identification and alerting the user of errors that can occur in the system (Nolan 2000). An example of a system error that can occur in the hospital is a wrong drug package that reaches the patient not from an error due to human factors but due to wrong labeling by one of the bar code printers in the pharmacy dispensing unit. If the patient consumes the wrong package, then there are chances of adverse events occurring and the patient developing a complication. Hence, ideally such errors should be identified by having manual checks along with system checks. A system check would involve scanning the barcode of the package at every stage to demonstrate that it is going to the right patient. A manual check involves checking the patient drug packages for the exact patient identifiers and the list of drugs in the content. Hence in general, both the system and the manual factors need to be crosschecked by the opposing system (WSNA 2005). Human Factors Human factors play a vital role with relation to proper management of error. In general an error is a mistake that occurs during any kind of human intervention and mostly blame is placed on another person for goof-ups made during the process. According to Sender error can occur from the standpoint of the person and can include errors or mistakes. According to Reason, human performance has 3 processes skill-based performance, rule-based performance and knowledge-based performance, and at each of these human performances, errors can occur. Skill-based performance is performed at the unconscious level (more often automatically), rule-based occurs at the conscious level (by cognitive processes and slightly through routine) and knowledge-based occurs at the conscious level (more often through cognitive). A skill-based error occurs due to a glitch in autonomic nervous activity, rule-based errors occur from making mistakes with interpretation of data or rules due (forgetting the rule of drug administration), and A knowledge-based error occurs when unexpected results are obtained, mainly due to applying medical knowledge in a wrong manner. Reason further defines an error to occur due to a breakdown in the intended processes and cannot occur by chance (Kopec, 2007):- Human Performance Steps There is huge responsibility on the person who makes a decision of what constitutes an error and the application of knowledge in order to prevent the occurrence of the error (Kopec, 2007). The IOM (Institute of Medicine) considers that medical error constitutes not only an unintended outcome but also a wrong use or a wrong plan to achieve a particular objective. They gave huge emphasis to the fact that medical errors could be preventable by reducing inappropriate or unsafe treatment processes, or using a computational system that can help perform system checks so that errors can be avoided (Patel, 2004). The annual mortality rate from medical errors in the US is about 50000 to 100,000, and most of these are from poor medical knowledge, wrong interventions, or due to improper treatment. About 10 to 20% of these errors are made whilst transcribing prescriptions and again this is significant human performance factors that can be overcome (Patel, 2004). The costs of medical errors may be high, as rectification of patient safe is costly, and often to rectify the error would be traumatic for the hospital and the patient (Patel, 2004). Most errors occur as a result of perception or negligence, but some people consider it to be an effect rather than a mere cause. However, a more neutral comment would be that medical error are in fact deviations from what is expected or desired in the healthcare system . An interesting observation of an error in the system is that it need not always have consistent effects and human systems work in such a manner. For example, an error does not need to have an adverse event, nor can an adverse event occur as a result of an error. A drug given wrongly or at a wrong time, may not produce any negative effect, however, a drug given perfectly may have huge negative effects even though no error is committed (Kopec, 2007). An error can prolong stay by about 2 days and cost the patient and additional $5000, whereas the annual spending would be about $10 billion and about 2.5 million hospital days every year. In actual sense, these can be avoided (Patel, 2004). At the human resource level, in the hospital at least one serious error is committed each day, and the turnouts are serious. Most patients approach the courts seeking justice, and the impact is serious in case of patient mortalities. The onus is placed back on the hospital by the courts, government, insurance companies, accreditation organizations and the CMS. The plan is to implement better system checks and computerized systems in order to reduce the errors on human processes. Such costs are no more payable by the Medicare or insurance companies (Patel, 2004). In healthcare, the medical error may be related to various processes in the hospital including Professional Practice such as drug administration , procedures, systems, prescriptions, order entry, bar coding, packaging, dispensing, drug nomenclature, administration, distribution, transferring, patient education, and monitoring which invariable involve human factors. Conclusion In general, to have computerized ordering system for drugs can help reduce the medical errors which can be prevented significantly and thus reduce the mortality rates from adverse events and the complications that may arise. However, efforts should be made to have system checks of the various human factors that would operate in the new ordering system. This includes alerts, bar coding, messaging, process checks, label identification and scanning, interaction checker, dose calculators, etc. By incorporating such a system in the hospital, there are chances the preventable medical errors can be significantly reduced and the direct and indirect costs be avoided. Since excessively liabilities are being placed on the hospital to reduce such errors, efforts would be made to use a system of double check at each level (system check as well as manual check). The efficiency of such a system would improve month only the patient safety but also ensure that physicians and nurses can attend to a greater number of patients. The quality standards would improve and now hospitals would be in a better position to practice evidence-based medicine. The cost implication of a computerized system to manage patient safety may be high initially, but slowly such a system would be paying huge dividends, and costs would be reduced in several spheres. Finally, the hospital is in a better position to take on advanced IT implementations that can further improve the quality of care, and improve the competitiveness of the hospital. Thus managing patient safety is an important aspect. Bibliography AHRQ 2008. What Exactly Is Patient Safety? [online] Available: http://www.ahrq.gov/downloads/pub/advances2/vol1/Advances-Emanuel-Berwick_110.pdf Dixon, B. E. 2009. “Inpatient Computerized Provider Order Entry (CPOE) Findings from the AHRQ Health IT Portfolio.” [online] Available: http://healthit.ahrq.gov/images/jan09cpoereport/cpoe_issue_paper.htm Goldberg, L.A. 2003. “Closed-loop Medicines Management System”. Hospital Pharmacy Europe. www.gs1eg.org/Download-Library-pdf?pdf_18.pdf Kopec, D. 2007. “The State of the Art in the Reduction of Medical Errors.” CUNY. [online] Available: http://www.sci.brooklyn.cuny.edu/~kopec/Publications/Publications/R_28_M.pdf Koppel, R. 2008. Feature Article: An Introduction to Computerized Provider Order Entry (CPOE), [online] Available: http://www.cceb.upenn.edu/news/?id=214&category=2 Manganelli, J. 2009. “Preventing Medication Errors.” [online] Available: http://www.bapainfo.org/html/documents/med-errors.ppt Massachusetts Coalition for the Prevention of Medical Errors 2006. “MHA Best Practice Recommendations to Reduce Medication Errors.” [online] Available: http://www.macoalition.org/documents/Best_Practice_Medication_Errors.pdf Massachusetts Hospital CPOE Initiative 2005. “CPOE Readiness Roadmap Guide.” [online] Available: http://www.masstech.org/ehealth/cpoe/Roadmap.pdf Mitchell, P. H. 2008. Chapter 1Defining Patient Safety and Quality Care. Patient Safety and Quality. [online] Available: http://www.ncbi.nlm.nih.gov/books/NBK2681/ Nolan, T. W. 2000. System changes to improve patient safety. BMJ, 320 doi: 10.1136/bmj.320.7237.771. http://www.bmj.com/content/320/7237/771.full Patel, R.B. 2004. “Reduction in Medication Errors in Hospitals.” CWRU. [online] Available: http://www.cwru.edu/med/epidbio/mphp439/Reduction%20in%20Medication%20Errors%20in%20Hospitals.htm Pope, A. 2010. “Introduction.” [online] Available: http://panko.shidler.hawaii.edu/HumanErr/Intro.htm Reason, J. 1990. Human Error, Cambridge University Press, Cambridge. The Leapfrog Group 2011. “Leapfrog CPOE Evaluation Tool.” [online] Available: https://www.leapfroghospitalsurvey.org/cpoe/index.asp Tully, M. 2007. “Patient Safety Research Programme: Medication errors 2: Pilot study.” [online] Available: http://www.haps.bham.ac.uk/publichealth/psrp/documents/PS020_Final_Report_Cantril.pdf Washington State Nursing Association 2005. SYSTEMS ISSUES AND HUMAN FACTORS. [online] Available: http://www.wsna.org/Topics/Patient-Safety/Systems-Issues-Human-Factors/ Read More