Medical Errors within the U.S. Healthcare System


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Medical Errors within the U.S. Healthcare System

  2. 2. HIGHLIGHTS S Introduction to common Hospital and medication Errors S IOM’s impact on tracking and reducing hospital errors S The Pro’s and Con’s of the IOM’s Recommendations S An alternative plan for reducing and tracking hospital errors S Alternative plan’s impact on hospital errors and it’s sustainability
  3. 3. What’s a Medical/Medication Error S A Medical Error is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome behavior, infection, or other ailment. S A Medication Error is any incorrect or wrongful administration of a medication, such as a mistake in dosage or route of administration, failure to prescribe or administer the correct drug or formulation for a particular disease or condition, use of outdated drugs, failure to observe the correct time for administration of the drug, or lack of awareness of adverse effects of certain drug combinations
  4. 4. Common medical and medication Errors S Common medical errors that take’s place within today’s hospitals are: S Common medication errors that takes place within today’s hospitals are: S Diagnostic errors S Ordering errors S Treatment and prevention errors S Transcribing errors S Miscellaneous errors (i.e. communication, equipment and systemic failures). S Dispensing errors S Administrating errors S Monitoring errors
  5. 5. IOM TO THE RESCUE ??? S
  6. 6. The IOM’s Contribution S The Institute of Medicine (IOM) is an independent, nonprofit organization that works outside of government to provide unbiased and authoritative advice to decision makers and the public. S In 1999, IOM published a research report titled “To Err is Human: Building a Safer Health System “ S The report was used to help formulate four specific recommendations for tracking and diminishing errors within a hospital setting.
  7. 7. Idea’s for addressing hospital Errors S 1st RECCOMENDATION S 2ND RECCOMENDATION creating a center for patient safety within the agency for healthcare Research and Quality. S 3RD RECCOMENDATION S The establishment of mandatory and voluntary reporting systems. S 4th RECCOMENDATION S S Creating safety systems inside healthcare organizations through safe practice implementations’ at the delivery level of care. S Raise standards for improvement in safety through the actions and oversight of organizations, group purchasers and professional groups
  8. 8. Did the IOM Succeed? S Five years since these recommendations were entertained by the U.S. Congress for proposed implementation at the federal level, the rate of medical and medication errors has remained relatively “high” S Extensive research performed in 2004 year suggested that medical errors still remained high, including several issues regarding substandard patient care with errors S The IOM failed to fulfill its expectations of a 50% reduction in medical/medication errors based upon the institute's recommendations.
  9. 9. Why did the IOM Fail? PROS S The creation of center for patient safety within the agency was realized. S IOM’s 4th recommendation has sparked the evolution of technology advanced health safety systems (I.E. Health IT systems). CONS S Compliance with mandatory and voluntary reporting systems has been inconsistent due to physician's fears of malpractice lawsuits and financial penalties. S Business groups such as “Leapfrog” have designed tools that inaccurately capture hospital error costs. S Newly developed Health safety IT systems have added to medical errors within many hospitals.
  10. 10. Hospital Errors are still a problem Medical Error Mortality rate of 2004 Medical Error Mortality rate of 2012 S 195,000 Americans died as a result of preventable errors . S 134,000 Americans died as a result of preventable errors. S Overall costs attributable to hospital errors was around $25 billion. S Overall costs attributable to hospital errors was $19.5 billion. S Bed sores, failure to rescue, and post-operative respiratory failure were the most common errors. S Patient misidentifications, medical equipment misuse and misdiagnosis were the most common errors.
  11. 11. Numbers Don’t Lie 2012 Incident report 12% 63% 25% 63% clinical process staff behavior medications
  12. 12. IS THERE AN ALTERNATIVE??? “To reduce the amount of hospital errors, a more comprehensive approach is needed” ~ FDA S
  13. 13. All Hands on Deck S The “All Hands on Deck” Patient Safety plan is a four part collaborative plan involving the IOM, state legislatures, the Food and Drug Administration and the Department of Health and Human Services. The plan is as follows: S A team of adverse medical event researchers and analysts, affiliated with the IOM, will be acquiring all relevant medical and medication error data (i.e Inpatient, Outpatient and Ambulatory). S California’s “Voluntary reporting bill” will be presented to all other state’s legislature in an effort to implement this version of the bill to increase physician error reporting. S Health business groups with proposed calculating cost tools for hospital errors will go through a Health business oversight and regulatory committee as an extension of HHS (Health and Human Services) department. S Proposed health IT systems and tools shall go through the “risk-based regulatory framework” headed by the FDA for approval to ensure it’s
  14. 14. Benefits and Drawbacks Benefits Drawbacks S S It’s a comprehensive effort at the state and federal level to exclusively target and reduce hospital errors. S The plan doesn’t take into account nursing and retirement home errors. S “Cash Strapped” hospital budgets might stop the plan’s full implementation. S S The plan hinges on U.S. Congressional approval for complete operation and implementation. The plan’s costs is a little under a $1 million dollars to operate. It broadens the scope of Health regulatory agencies involving the public’s health and well being.
  15. 15. Is there a “Backup Plan” S If Congress rejects “All Hands on Deck”, a contingency plan for targeting and reducing hospital errors will follow. S The plan will consist of representative’s from the IOM visiting only those hospitals ranked “High” on the mixed method analysis; where information and training sessions will be held on monthly basis. S sessions will give patients, physician and other allied health professionals information regarding their hospital’s error rates and ways in which these error rates can be improved. S This plan will be of “no charge” to the hospital and patients that sign up.
  16. 16. “All Hands on Deck” is Worth It!!! S In order to effectively impact the rise and cost of medical errors to healthcare, we need a collective effort at the state and federal level. S If hospitals want to attract more patients, developing a culture of patient safety would be in their best interest towards achieving a quality of care standard that separates them from the competition. S While this plan leaves out the reduction of medical errors in nursing homes, a significant majority of medical errors within hospitals are researched, evaluated and regulated under this collaborative effort.
  17. 17. QUESTIONS???
  18. 18. References S The Institute of Medicine. (2013). Medical errors and the Institute of Medicine (IOM). Premier: Transforming Healthcare together. Premier, Inc. S Agency for Healthcare Research and Quality (AHRQ) (20130). Voluntary Patient Safety Event Reporting (Incident Reporting). Department of Health and Human Services. S Gideon, G. (2010). Medical Errors tied to patient transfers. White Coat Notes: News from the Boston Area medical community. S U.S. news and world report. (2010). Cost of medical malpractice tops $55 billion a year in the U.S. USN Health Day. S Binder, L. (2013). Leapfrog defends methodology. Modern Healthcare, 43(32), 24. S Foster, N. (2013). Leapfrog tool 'seriously flawed'. Modern Healthcare, 43(31), 16. S Conn, J. (2013). Targeting adverse events. Modern Healthcare, 43(27), 10. S Lentz, R. (2001). Quiet Report. Modern Physician, 5(9), 2. S Bleich, S. (2005). Medical Errors: Five Years After the IOM Report. The commonwealth fund