Bandolier 28 reported on a study from Boston showing that about 2000 adverse drug
events per hospital occur each year. An ADE was defined as an injury resulting from
medical intervention relating to a drug. The importance of preventable errors has
been brought home by surveys showing that they impose major burdens on health
services, and may injure or even kill thousands of patients a year. It is probably a
much bigger problem than hospital acquired infection, and a serious and thoughtful
paper [1] quotes one estimate of 180,000 people dying every year in the USA at least
in part due to iatrogenic injury. These episodes are also expensive. The estimated
cost is $4,000 per event in the USA.
Systems causes of error
The question left begging is how to prevent what has been called serious medical
error. This is not a pejorative phrase. It is not intended to blame individuals, but
rather a complaint that healthcare professionals are too often expected to do too
much with too few tools. Most errors result from failure to use basic human factors
in the design of tasks and systems. Excessive reliance on memory, lack of
standardisation, inadequate information availability and poor work schedules create
situations in which individuals are more likely to make mistakes.
One of the biggest problems is in measuring errors. Leape makes the point that the
rates of medical errors reported vary by a factor of at least 50-fold (Table).
Voluntary self-reporting gives low rates, while the use of chart reviews and computer
screening provides much higher rates. The paper examines a variety of different
factors that contribute to medical error:
|
Method of detection
|
Errors (%)
|
|
|
|
|
Voluntary self-reporting
|
0.20
|
|
Patient review
|
0.70
|
|
Computer screening
|
3.80
|
|
Chart review
|
6.50
|
|
Chart review + computer
|
10.00
|
Process design
failures
result from the failure to analyse the purposes of a system and how they can
best be achieved, relying on the ways things were, perhaps. This is a big effect,
may be the cause of about half of all errors. An example may be over-reliance on
memory rather than having computerised systems to help.
Task design
failures
result from failure to incorporate human factors. Checklists, protocols and
computerised decision aids (again) can help reduce this. Standardise and simplify
might be the simple message here. An example might be to standardise
postoperative analgesia protocols in an institution, locking into a system the
impossibility of choosing wrong drugs or dosages and making everyone familiar
with one system.
Equipment design
failures
arise from the bewildering number of different machines used in a hospital with
so few people fully knowing how to use them. Should it be possible, for instance,
to connect an epidural catheter to a syringe with a drug prepared only for
intravenous use?
Organisational and environmental
failures
come from overall cultures in organisations, such as how it deals with issues of
quality, training, and team building. Put simply, this comes down to a simple
question: does the organisation care? If it doesn't, then why should its workers?
The big picture
If this sounds boring process gobbledegook, then it shouldn't. This is a
thoughtful exposition of the problem from an author who has spent time thinking
about it, in the Harvard Health Policy and Management Department. Healthcare
systems are big, they are complex, they are often impersonal, and are difficult
to change. Change comes not from one big idea, so beloved by governments and
politicians, but by doing the right things better and continuing to do so. For
anyone starting down that long road, this paper gives a good place to get the big
picture before getting overwhelmed by the underbrush of detail.
Reference:
- LL Leape. A systems analysis approach to medical error. Journal of
Evaluation in Clinical Practice. 1997 3: 213-222.
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