1. Preventing Medical Errors: Technical, Ethical and Social Issues J.G. Anderson, Ph.D. E.A. Balas, M.D., Ph.D. D.W. Bates, M.D. R.S. Evans, Ph.D. G.J. Kuperman, M.D., Ph.D. P. Winkelstein, M.D.

2. Top Ten Causes of Death in the U.S., 1997

3. Types of Errors

4. Institute for Safety Medication Practices Field Study of 320 Hospitals Lack of integration between POE and pharmacy systems Lab system not integrated with medication order system No link between IV system and medication order system No clinical order screening Only 13% of hospitals had POE capability

5. Institute for Safety Medication Practices Field Study of 320 Hospitals Complex order entry system Drug information is difficult to access System does not prompt for dangerous situations System does not allow access to previous patient encounter information System generates hard to read labels and confusing abbreviations

6. Case A 35-year old woman was admitted to the emergency department of a hospital in the Northwest with high spiking fever and rigor. Laboratory tests were ordered. The woman latter was admitted to the ICU with a presumed diagnosis of sepsis when her blood pressure dropped. The computerized ordering systems in the two departments were independent. An ICU physician ordered an anti-bacterial medication (ampicillin) but the pharmacy filled the prescription with an antiviral medication (Acyclovir). By the time the error was detected, the woman suffered irreversible brain damage.

7. Case A small hospital hired consultants to design and implement a computer-based pharmacy system. The system that was implemented included data-handling and user interface features from a warehouse inventory system. Within months, the hospital decided to return to the paper-based system because of medication errors. The new system eliminated much of the oversight provided by the staff. As a result doctors, nurses and pharmacists all blamed someone else for errors.

8. Computer Simulation Objective: To evaluate the effectiveness of information systems applications designed to detect and prevent medication errors Methods: Drug orders were reviewed on 2 medical-surgical units for a 12 week period Simulation: Drug orders were simulated on 14 medical-surgical units over a 52 week period

9. Clinical Information System Applications [BL] Existing information system [1] Computer-based physician order entry system that provides dosing information and parameters about drugs at the time orders are written [2] Direct order entry into the HIS by physicians [3] Computer system surveillance of potential ADEs based on clinical data [4] Use of the HIS to simultaneously implement all three applications

10. Estimated ADEs by Intervention

11. Estimated Additional Days of Hospitalization by Intervention

12. Estimated Additional Hospital Costs by Intervention

13. Implications It is important to view medical errors from a systems perspective. Most medical errors are not detected by voluntary reporting systems. Prevention efforts focused on a single stage of the process have limited impact on medical errors. System-wide changes are required to significantly reduce medical errors. Clinical information systems are a cost-effective means of preventing medical errors.

14. Solutions to Major Medical Errors are Perceived as Expensive Barcoding Positive Patient ID Physician Order Entry Integrated Databases Decision Support Systems

15. But They Have Major Payoffs Medical error reduction can save money Higher quality care can be cost-effective Their can be potential savings of as much as $2,013-3,244 per occurrence, primarily attributable to increased length of stay

16. Responses to the IOM Report JCAHO - Establish disease-specific care performance indicators and mandatory reporting for accreditation Government - Create incentives through reimbursement. Monitor provider organizations through reporting

17. Responses to the IOM Report Providers - Implement tools that support clinical decision making Employers - Provide incentives to providers hat use tools to increase safety