Hobgood C, Peck C, Gilbert B, Chappell K, Zou B
University of North Carolina: Chapel Hill, NC.
OBJECTIVES: To determine how and when the public wishes to learn
of health care errors and assess the degree of error the public
believes should be reported to government reporting agencies, state
medical boards, and hospital patient safety committees. To evaluate
what role the public believes medical educators should play in this
process. METHODS: A 12-item survey was administered to a
convenience sample of emergency medicine patients and families
during their evaluation in a level-one academic trauma center.
Results were tabulated for each positive response and data reported
as percentage. Data were analyzed using chi-square. RESULTS: 258
surveys were returned (80%). A majority of patients wished to be
informed immediately of any medical error (76.4%) and to have full
disclosure of the error's extent (88%). Patients believe mistakes
that affect the health of the patient should be reported to
government agencies (54%), to state medical boards (63%), and to
hospital committees (50%). Half of respondents also believe that
even trivial mistakes should be reported to a hospital patient
safety committee. Respondents believe medical educators should
teach students to: be honest and compassionate (38%), tell patients
about mistakes (25%), and develop systems to detect medical
mistakes (17%). No respondent felt teachers should punish students
who commit an error. The frequency of hospital admission, or
physician visits per year had no impact on response pattern (chi(2)
= ns) CONCLUSIONS: Regardless of health care utilization, a
majority of patients want full disclosure of any medical error and
wish to be informed of the error immediately upon its detection.
Surprisingly, only slightly more than half of patients support
reporting of significant errors to government agencies (54%) or the
state medical board (63%). The public believes medical educators
should avoid reprisals for errors during training.
Acad Emerg Med 2001 May; 8(5):498
Assessing Professional Behaviour and Medical Error
Hebrew University Faculty of Medicine, Jerusalem, Israel.
The mission of medical schools underwent significant change in
the post-Second World War period, which resulted in a deevaluation
of teaching, which in turn impacted on the type of assessment
methods that emerged in the latter part of the twentieth century.
Assessment based on direct observation did not receive the same
degree of attention as methods such as multiple choice question and
the objective structured clinical examination. During the past two
decades medical educators have begun to emphasize the importance of
teaching and assessing professional behaviour. It is suggested in
this paper that assessment of professional behaviour can best be
achieved by means of direct observation. A review of the area of
assessment of clinical competence over the past 50 years reveals
that it has been dominated by assessment methods that for the most
part have been removed from the clinical setting in which medical
students work and learn. In this paper it is proposed that there is
a need to focus attention on methods of assessment which are based
on the direct observation of performance that can be used in the
clinical setting. Specifically, more attention needs to be directed
at two areas of performance: (1) professionalism, and (2) medical
error, both of which have given rise to increasing concern in the
medical profession, healthcare agencies and the public at
Med Teach 2001 Mar; 23(2):145-151
Reducing Adverse Drug Events: Lessons from a Breakthrough
Leape LL, Kabcenell AI, Gandhi TK, Carver P, Nolan TW, Berwick DM.
Harvard School of Public Health, Boston, MA 02115, USA.
BACKGROUND: In January 1996, 38 hospitals and health care
organizations (for a total of 40 hospitals) in the United States
came together in an Institute for Healthcare Improvement (IHI;
Boston) Breakthrough Series collaborative to reduce adverse drug
events-injuries related to the use or nonuse of medications.
METHODS: The participants were taught the Model for Improvement, a
method for rapid-cycle change and evaluation, and were then coached
on how to identify their own problem areas and develop changes in
practice for rapidcycle testing. These changes could be
implementation of one or more known medication error prevention
practices or new practices developed. RESULTS: During a 15-month
period the 40 hospitals conducted a total of 739 tests of changes.
Process changes accounted for 63% of the cycles; the remainder
consisted of preliminary data gathering, consensus-building, or
education cycles. Eight types of changes were implemented by seven
or more hospitals, with a success rate of 70%. These changes
included non-punitive reporting, ensuring documentation of allergy
information, standardizing medication administration times, and
implementing chemotherapy protocols. DISCUSSION: Success in making
significant changes was associated with strong leadership,
effective processes, and appropriate choice of intervention.
Successful teams were able to define, clearly state, and
relentlessly pursue their aims, and then chose practical
interventions and moved early into changing a process. They did not
spend months collecting data before beginning a change. Changes
that were most successful were those that attempted to change
processes, not people. Health care organizations committed to
patient safety need not regard current performance limits as
Jt Comm J Qual Improv 2000 Jun;26(6):321-31
Anonymous Error Reporting as an Adjunct to Traditional
Incident Reporting Improves Error Detection.
Sucov A, Shapiro MJ, Jay G, Suner S, Simon R.
University Emergency Medicine Foundation: Providence, RI,
Dynamics Research Corporation: Andover, MA.
OBJECTIVES: To compare rates of error reports from traditional
hospital incident (IR) and newly instituted anonymous error
reporting (AER) systems for identification of medical error and
quality improvement (QI) opportunities in the ED. METHODS: A
prospective observational study was conducted in an urban,
adult-only level 1 trauma center with EM residency from 8/21/00 to
11/28/00. A voluntary, anonymous, non-punitive error reporting
system was initiated as a formal patient safety initiative.
Physicians and nurses were encouraged to report events where an
error occurred or there was a "near miss" regardless of actual
patient harm. A multidisciplinary, peer-review patient safety
committee reviewed the first 3 months of AERs and performed
root-cause analysis for QI opportunities. IRs were tabulated as per
routine and correlated with AERs: Major outcome variable was number
of reports from both systems, compared by chi squared. RESULTS:
18,364 patients were seen during the period studied. Significantly
more AER than IR reports were submitted. 79 AER (4.3/1,000 visits,
95% CI 3.4, 5.3/1,000) and 27 IR (1.5/1,000 visits, 95% CI 0.9,
2.1/1,000) were generated (chi squared = 25.6, p < 0.001). Most
common AERs were failure to diagnose/treat (32%), communication
errors (25%), system delays (24%), and medication errors (11%).
Most common IRs were falls (22%), elopement (22%), system delays
(15%), and medication errors (15%). Only 4 AERs and IRs overlapped;
1 failure to diagnose/treat, 2 medication errors, and 1
communication error. None of the AERs or IRs were reported through
the compulsory statewide reporting system. CONCLUSIONS: AER system
has a greater reporting rate as compared to traditional IR. AERs
and IRs were used by staff for different issues, and are best used
as adjuncts to more completely identify error patterns and QI
Acad Emerg Med 2001 May 8(5):498-9
Pharmacist participation on physician rounds and adverse drug
events in the intensive care unit.
Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI, Bates DW.
Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass 02115, USA.
CONTEXT: Pharmacist review of medication orders in the intensive
care unit (ICU) has been shown to prevent errors, and pharmacist
consultation has reduced drug costs. However, whether pharmacist
participation in the ICU at the time of drug prescribing reduces
adverse events has not been studied. OBJECTIVE: To measure the
effect of pharmacist participation on medical rounds in the ICU on
the rate of preventable adverse drug events (ADEs) caused by
ordering errors. DESIGN: Before-after comparison between phase 1
(baseline) and phase 2 (after intervention implemented) and phase 2
comparison with a control unit that did not receive the
intervention. SETTING: A medical ICU (study unit) and a coronary
care unit (control unit) in a large urban teaching hospital.
PATIENTS: Seventy-five patients randomly selected from each of 3
groups: all admissions to the study unit from February 1, 1993,
through July 31, 1993 (baseline) and all admissions to the study
unit (postintervention) and control unit from October 1, 1994,
through July 7, 1995. In addition, 50 patients were selected at
random from the control unit during the baseline period.
INTERVENTION: A senior pharmacist made rounds with the ICU team and
remained in the ICU for consultation in the morning, and was
available on call throughout the day. MAIN OUTCOME MEASURES:
Preventable ADEs due to ordering (prescribing) errors and the
number, type, and acceptance of interventions made by the
pharmacist. Preventable ADEs were identified by review of medical
records of the randomly selected patients during both
preintervention and postintervention phases. Pharmacists recorded
all recommendations, which were then analyzed by type and
acceptance. RESULTS: The rate of preventable ordering ADEs
decreased by 66% from 10.4 per 1000 patient-days (95% confidence
interval [CI], 7-14) before the intervention to 3.5 (95% CI, 1-5;
P<.001) after the intervention. In the control unit, the rate
was essentially unchanged during the same time periods: 10.9 (95%
CI, 6-16) and 12.4 (95% CI, 8-17) per 1000 patientdays. The
pharmacist made 366 recommendations related to drug ordering, of
which 362 (99%) were accepted by physicians. CONCLUSIONS: The
presence of a pharmacist on rounds as a full member of the patient
care team in a medical ICU was associated with a substantially
lower rate of ADEs caused by prescribing errors. Nearly all the
changes were readily accepted by physicians.
JAMA 1999 Jul 21;282(3):267-70
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