Preventable Medical Errors

Preventable Medical Errors

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Using technology to reduce medical errors

According to the American Association for Justice, 440,000 people die annually from preventable medical errors, making it the third leading cause of death in the United States. Because of the frequency and consequences of medical errors, from patient risk to the billions of dollars a year in increased costs worldwide, health systems are taking a harder look at medical error prevention. In this article, we’ll examine the types of medical errors, what is responsible for a majority of the nation’s medical errors, and how healthcare organizations are using technology and their own IT systems and processes as a strategy of prevention.

Types of Medical Errors

From hospitals and healthcare centers to pharmacies, nursing homes and labs, medical errors can occur from lack of information, training or experience, but also due to the sheer complexity of the healthcare system. Some of the most common medical errors involve:

  • Medication management: This most often occurs when the patient receives the wrong drug or dosage, form, quantity, route or concentration; fails to receive the drug at a proper time, or if the drug was administered incorrectly. Medication errors often go undetected, and may not seriously impact a patient. However, some medication errors cause adverse effects and even death.
  • Diagnosis: In a study done by the Harvard Medical Practice, diagnostic error accounted for 17% of preventable errors in hospitalized patients. Common diagnostic errors include cognitive biases based on patient histories, impressions, cues or other information.
  • Surgery: Surgery errors occur when a patient has the wrong surgery, at the wrong time, at the wrong site or by the wrong surgeon. This can often be caused by poor teamwork or communication between physicians and staff, as well as lack of adequate systems and procedures in place. In addition, without proper monitoring and care post-surgery, patients can suffer from complications after surgery.
  • Equipment: While technology helps providers to treat patients more effectively, the use of equipment can also lead to medical errors. Some of these errors occur due to lack of proper equipment, improper configuration or settings, and malfunctioning of equipment during use.
  • Labs and Reporting: While standards exist to control the quality and safety of laboratory testing, errors still occur. Most laboratory errors occur in the pre- and post-analytical stages, such as test order entry, incorrect patient identification, not property collecting or preparing specimen for testing, interferences during testing, or not interpreting or verifying results correctly.

Ways to prevent medical errors:

A variety of methods can help providers avoid medical errors in the healthcare setting. Some of the more popular and more successful ways include:

  • Updated Patient Information: Clinicians must receive accurate, updated patient medical records and data at the time of decision-making. This often comes from keeping an updated electronic health record (EHR) system for all patients in the practice or hospital, with automated notes and records, order entry and clinical decision support.
  • Enterprise Master Patient Index (EMPI): This aggregated database uses a unique patient identifier, along with other demographic patient data, to maintain accurate and updated medial data on a patient across the enterprise – including between hospital systems and departments. The purpose of an EMPI is to consolidate duplicate patient records and prevent identity errors within the organization’s entire software system, while keeping all of the information updated when it changes.
  • Personal Health Records: Patient portals offer another way for both patients and caregivers to update personal health records (PHRs) and updated critical health information. Using PHRs creates a more patient-centric experience as it empowers patients to own and understand their own healthcare, resulting in fewer errors.
  • Adequate Monitoring: Whether it’s a patient receiving care for a chronic condition or a patient recovering from surgery, proper monitoring from staff as well as medication management programs and electronic patient tracking systems can help prevent complications, identify errors and reduce readmissions.
  • Trained, Supervised Staff: Personnel should be taught systems for ordering, and administering medication, learn about common risk factors, and perform safety and quality checks to ensure the patient’s health.
  • Procedure Checklists: To solve the issue of procedure errors, the World Health Organization developed an operating room checklist to ensure equipment was in proper use, as well as to define pre- and post-operative procedures. These checklists and process improvements reduced equipment error by an average of 49 percent.
  • Determining Potential Errors in Advance: Identifying and documenting common errors in the system and processes may help healthcare organizations lower error rates in the future. Healthcare organizations should also encourage, support and reward the reporting of errors.
  • Informed Patients: Pharmacists, nurses and physicians can do their part by counseling patients on medication use, drug interactions and side effects so that they understand potential complications. Keeping both patients and caregivers informed on diagnoses, testing and lab results will also enable them to correct any errors or prevent duplications in testing or treatment. Patients can be informed in person, via patient information sheets or even via the patient portal.
  • Computerized prescriptions: Using electronic order entry helps physicians and pharmacies check for correct drug, dosage form, allergies, drug-to-drug interaction and updates from the manufacturer. Boston’s Brigham and Women's Hospital has been using computerized prescription writing since 1994, reducing serious medication errors by 55 percent.
  • Bar-coded prescription administration: Within hospital settings, this technology requires scanning the patient's identification bracelet and the unit dose before administering medication, with system alerts for any mismatching of patient, drug, dose, route, or time.
  • Accountable Care: With government incentives and penalties for non-compliance in place, more providers are feeling pressured to improve efficiencies, engage patients via online portals, as well as view, download and transmit patient information electronically. These steps will ensure that providers are ready to property manage patient care, and will help them reduce errors and readmissions in the process.

Designing a System to Prevent Medical Errors

One of the best ways to incorporate some of these methods into your day-to-day operation is to work with your IT team to design an organizational system with identified procedures, processes and accountable staff, and include ways to document ordering and error tracking. Do the errors come from lack of training in the system, not using the system, improper transcription or a lack of integration between systems? At CoreTech Revolution, we help providers with workflow analysis, EHR and HIE systems integration, patient portal setup and staff training and education. Once healthcare organizations have taken these necessary steps, they will be much less likely to experience medical errors in the future, and can also enjoy increased efficiencies, along with greater patient satisfaction and outcomes.