Chapter 14 Medical Errors An Ongoing Threat to Quality Heal.docx

Chapter 14
Medical Errors: An Ongoing Threat to Quality Health Care
Copyright © 2016 Wolters Kluwer Health | Lippincott Williams
& Wilkins
Copyright © 2020 Wolters Kluwer • All Rights Reserved
Definitions
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
Adverse events: adverse changes in health occurring as a result
of treatment
Adverse drug event when medications involved
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)

“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
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
Question #1
Is the following statement true or false?

Adverse events result from treatment.
Answer to Question #1
True
Adverse events are defined as adverse changes in health that
occur as a result of treatment.
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
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

The National Quality Strategy: Aims, Priorities, and Levers (see
Box 14.3)
Six priorities
Eight levers
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
The Joint Commission
Comprehensive database of sentinel events
Root cause analysis; Sentinel Events Policy

Failure mode and effects analysis (FMEA)
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)
Centers for Medicare and Medicaid Services (formerly HCFA)
Medicare Improvements for Patients and Providers Act (2008)
“Never events” (see Box 14.5)
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
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
C
The National Priorities Partnership developed from the work of
the National Forum for Health Care Quality Measurement and
Reporting.
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
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
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
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”
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)
Question #3
Is the following statement true or false?
A sigma value of three indicates lower performance than a
sigma value of five.
True
A sigma value is a statistical measurement that reflects
performance. Thus, the higher the sigma value, the better the

performance.
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
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”
Patient Safety

Solution
s
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
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

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.
End of Presentation

Chapter 14 Medical Errors An Ongoing Threat to Quality Heal.docx

Chapter 14 Medical Errors An Ongoing Threat to Quality Heal.docx

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