Preventing Hospital Errors to Improve Patient Care

Article contributed by: Emily Newhook, Community Relations Manager for MHA@GW at The Milken Institute School of Public Health at The George Washington University

Defining Adverse Medical Events

Mistakes can happen anywhere, but when it comes to fields like health care – where errors can have life-threatening consequences – we hold people to a higher standard. An adverse medical event (AME) is one such example. An AME — the result of a medical intervention rather than the underlying medical condition — is unintentional harm that can cause serious injury to a patient. AMEs run the gamut of medical problems and include hospital-acquired infections, catheter-acquired infections, surgeries done on the wrong patients or wrong area, leaving foreign bodies inside a patient after procedures, hospital falls and slips, incorrect medication and pressure ulcers among others.

AMEs can, and do, happen at any point in a patient’s care. A large proportion of AMEs are multifactorial, meaning a series of errors or miscommunications lead to the event rather than just one erroneous decision. But how do they happen?

Poor technology comprehension and utilization, management issues, communication failures, lack of resources, poor staffing levels and a lack of safeguard protocol are often to blame. Sleeplessness, written errors, misdiagnosis, poor performance and just plain poor judgment also contribute. Much has been done to develop evidence-based best practices and guidelines, checklists and safeguards. Individual health practitioners and health systems have put a myriad of both technologically advanced and basic analog safeguards in place; nonetheless, AMEs persist as a major problem for the medical community.

How Prevalent are Adverse Medical Events?

In 1999, the Institute of Medicine published a seminal report on AMEs, “To Err Is Human,” which brought to light the impact and frequency of medical errors. The report estimated that approximately 98,000 Americans died every year due to AMEs. Since then, this figure has been heavily circulated and reported, and after an initial period of disbelief, the medical community has accepted it.

A more recent work, a 2013 study published in the Journal of Patient Safety, contends that the number of patients whose deaths are hastened or caused by medical errors is much higher — between 210,000 and 440,000 deaths per year. This figure, if true, would put AMEs as the number three cause of death in the United States.

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While figures from this study have been broadly reported, they have not yet been verified and accepted widely by the medical community. While the research methods of the study were sound, many contend that the numbers were collected under the false assumption that all adverse events are preventable, leading to possibly exaggerated numbers. For example, even when the best evidence-based practices, such as the Surgical Care Improvement Project, are implemented nearly perfectly in colon surgery patients, at least 8-10 percent of patients develop serious infections. Meaning, a certain level of infections are not preventable and not due to medical error. Most in the medical community still cite the IOM figure of 98,000.

What Is Being Done to Prevent Adverse Medical Events?

Solving a complex, multi-causal problem like AMEs requires a flexible, multi-pronged approach. The general consensus is that the most fruitful solutions eliminate the systemic and organizational problems that give rise to a large proportion of errors – not only by introducing safeguards, but also by urging health care providers and systems to adopt a culture of safety. This culture of safety is incredibly important as it encourages medical professionals to find and report errors, instead of sweeping them under the rug. Patterns of behavior that support a culture of safety also reinforce and entrench these safer methods into the health system, making them a cultural norm.

A common tactic for reducing AMEs and other adverse events in the medical professions is a delightfully low-tech system: the checklist. Nurses, in particular, utilize checklists in their daily routines. Doctors have also developed lists to suit the needs of their patients and specialty. For example, Peter Pronovost at Johns Hopkins University Hospital developed a checklist that has been proven to drastically reduce the number of hospital-acquired infections.

Many hospital systems are turning to technology to aid them in reporting and spotting medical errors. The LDS Hospital in Salt Lake City uses a system called HELP (Health Evaluation through Logical Processing) to monitor signs of adverse drug events through routinely recorded medical information. The system searches medical records for indicators that a patient might be having an adverse drug event and, if found, the HELP system can alert hospital staff.

LDS Hospital has been able to significantly increase the amount of adverse drug events they identified, isolating these errors and improving practices to prevent the errors from happening in the first place. LDS also has a computer assisted antibiotic dose monitor that tracks patients on antibiotics to closely monitor their dosage. This system has reduced the total number of days patients spend in the hospital on antibiotics by optimizing their dosage. Finally, the hospital integrates information from the pharmacy, lab and other inputs to track and monitor drug allergies, reactions and errors in dose.

Hospitals in the state of Minnesota have long been leaders in tracking and reducing the impact of AMEs. In 2003, it was the first state to centralize and mandate reporting of AMEs through the statewide Adverse Health Care Events Reporting System. The system, administered by the Minnesota Hospital Association and the Minnesota Department of Health, was created by landmark state legislation. Because the system is centralized, it gives a common ground for all Minnesota hospitals not just to report AMEs but to share and collaborate regarding successes and failures when it comes to prevention techniques and tactics.

Despite all effort and subsequent success of the movement to reduce AMEs, it’s unlikely there will ever be a day when the threat is completely eliminated. Backup systems will fail and new complications may arise as technology continues to change the way health care is delivered. But, with dedication to reporting and fixing errors, health professionals and health systems can work together to diminish the risks as much as possible.

About the author: 

Emily Newhook is an outreach coordinator for the MHA degree program from The George Washington University, MHA@GW. Outside of work, she enjoys writing and powerlifting. Follow Emily on Twitter @EmilyNewhook and Google+.