Consider these tactics that analyze and address medical errors at a system level.
It’s human nature-everyone makes mistakes. But the consequences of those mistakes can range wildly not only according to their severity, but also depending on who commits them. When a marketer makes a typo on a press release, the worst case scenario is typically a minor loss of credibility. If a healthcare practitioner were to make the same mistake on a patient’s chart, say by accidentally prescribing clozapine instead of olanzapine (two “look-alike, sound-alike” drugs, which are often confused), the result could be catastrophic.
Despite the fact that the healthcare industry overall takes this responsibility very seriously, the CDC estimates 250,000 Americans die annually due to medical errors.
Of course, not all medical errors result in a patient death. In fact, many experts have suggested that the majority may have no tangible effect at all, and thus go unreported. Healthcare executives must not overlook these common, but less-serious errors. Aside from the possibility the next incidences of these errors could have more serious consequences, they also may provide critical insight into the systemic issues that allowed them to occur in the first place.
Thus, to tackle medical errors effectively, healthcare executives should take a step back, and consider tactics that analyze and address medical errors at a system level. Here are four ways how:
1. Monitor vulnerable populations. While medical errors affect a wide variety of patients, certain patients and populations are statistically at greater risk. A peer-reviewed white paper in the American Association of Critical Care Nurses, identifies these groups as: patients in isolation who may receive less contact with healthcare professionals; patients with limited English proficiency who may lack the native language proficiency which is often required to interpret complex medical instruction; and patients with low health literacy who may struggle to “adequately communicate with members of the healthcare team, fill out complex forms, and understand concepts related to risk and probability.” The 45% of the U.S. population with at least one chronic disease (
), and the 35.8% of U.S. adults taking five or more medicines, a practice known as polypharmacy, according to the Journal of the American Medical Association, are also at increased risk as a result of their increased touchpoints with the healthcare system-i.e., there is more opportunity for error. When it comes to these groups, simple steps such as remaining vigilant, implementing safeguards (e.g., biometric verification, etc.), and improving communication may dramatically reduce medical errors. Certain work processes within a hospital are also more vulnerable to errors. For example, a recent five-hospital observational study on the accuracy of preparing small- and large-volume injectables, chemotherapy solutions, and parenteral nutrition (PN) showed a mean error rate of 9%, meaning almost one in 10 products were prepared incorrectly prior to dispensing, according to the Institute for Safe Medication Practices. In this case, environmental changes, such as improvements to equipment or processes, may make a significant difference.
2. Promote interdisciplinary collaboration. When it comes to medical error prevention, the most obvious, and yet most neglected, tactic are often one in the same: improving and streamlining communication among links in the patient care chain (e.g., monitoring handoffs in communication). For example, in many hospitals, pharmacists-critical allies in the prevention of medical errors-are relegated to the basement in predominantly order fulfillment roles. They have limited face-to-face interactions with their colleagues in other departments, and even less with the patients they’re working to treat. One proven tactic to address this issue is to decentralize the pharmacy, positioning pharmacists as permanent resources in particularly vulnerable hospital departments, such as the ER, or otherwise, rotating them between these departments on a regular basis. Once on the patient floor, pharmacists may provide more comprehensive patient counseling (at which time, experts suggest
, serve as a second pair of eyes for nursing and physician staff, and oversee new automation technology (which, while designed to ultimately improve patient safety through the elimination of human error, in their transition period, can actually make hospitals more vulnerable to medical errors).
Next: Safety first
3. Engage patients in safety. While healthcare professionals should never rely on patients and their caregivers to take an active role in reducing medical errors (after all, even if it’s in their best interest to do so, it’s not always possible due to a lack of time, awareness, or knowledge), helping them work toward this goal can have a dramatic impact. As patients and their caregivers have a clear personal investment in patient safety, they’re arguably healthcare professionals’ most critical resource in promoting it. In light of this, hospitals should make an effort to empower patients to be their own strongest advocates-providing literature with tips they may have not considered (e.g., make sure your doctor knows about medications you’re taking; for healthcare procedures, elicit vocal agreement from you, your doctor, and the person who is administering the procedure on what’s about to be done, etc.), increasing their interface with pharmacists who are best equipped to answer their questions and concerns related to their medications (a huge component of medical errors), and encouraging them to educate themselves on their condition and the different treatment options available to them.
4. Encourage a high reliability culture. To prevent future medical errors, it’s imperative to ensure those that have already occurred are accurately reported. Unfortunately, in an effort to promote accountability for medical errors, many hospitals have unintentionally created a “punishment” culture which discourages accurate reporting. By doing their best to target behaviors rather than individuals, healthcare leaders may help ensure staff members are comfortable coming forward with knowledge of medical errors that have already occurred, as well as opportunities for medical errors, within their organizations. Other steps, such as simplifying reporting systems to make it easy for healthcare professionals to report errors when they first occur and worry about collecting secondary details later, can also help ensure medical errors don’t fall through the cracks. Finally, engaging an objective third-party organization to track and analyze medical errors is often a good idea-not only due to their likely expertise in the area, but also because their outside perspective may allow them to catch systemic issues that those closer to the organization may have missed. All of these tactics will help hospitals collect accurate data, and then triage to address the most dangerous errors for the quickest improvement in patient safety.
Kenneth Maxik has worked with interdisciplinary hospital teams for more than 20 years on quality, patient safety and compliance. In his role as director of patient safety at CompleteRx-a hospital pharmacy management and patient care company-he develops and annually updates a proprietary 250-point patient safety checklist for clients, including medical error measures, leveraging the data he collects to recommend protocols that improve patient safety at client facilities.