To Err Is Human Building a Safer Health System (2000) / Chapter Skim
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2 Errors in Health Care: A Leading Cause of Death and Injury
2 Errors in Health Care: A Leading Cause of Death and Injury
Pages 26-48
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From page 26... ...
hospitals in 1997, the results of these two studies imply that at least 44,000 and perhaps as many as 98,000 Americans die in hospitals each year as a result of medical errors.3 Even when using the lower estimate, deaths in hospitals due to preventable adverse events exceed the number attributable to the 8th-leading cause of death.4 Deaths due to preventable adverse events exceed the deaths attributable to motor vehicle accidents (43,458) , breast cancer (42,297)
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From page 27... ...
· Medication-related errors occur frequently in hospitals; not all result in actual harm, but those that do are costly. One recent study conducted at two prestigious teaching hospitals found that almost two percent of admissions experienced a preventable adverse drug event, resulting in average increased hospital costs of $4,700 per admission or about $2.8 million annually for a 700-bed teaching hospital.12 If these findings are generalizable, the increased hospital costs alone of preventable adverse drug events affecting inpatients are about $2 billion for the nation as a whole.
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From page 28... ...
prescription drugs are widely used, so it is easy to identify an adequate sample of patients who experience adverse drug events; (2) the drug prescribing process provides good documentation of medical decisions, and much of this documentation resides in automated, easily accessible databases; and (3)
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From page 29... ...
Although many focus on errors and adverse events associated with ordering and administering medication to hospitalized patients, some studies focus on patients in ambulatory settings. Adverse Events An adverse event is defined as an injury caused by medical management rather than by the underlying disease or condition of the patient.29 Not all, but a sizable proportion of adverse events are the result of errors.
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From page 30... ...
The most extensive study of adverse events is the Harvard Medical Practice Study, a study of more than 30,000 randomly selected discharges from 51 randomly selected hospitals in New York State in 1984.3° Adverse events, manifest by prolonged hospitalization or disability at the time of discharge or both, occurred in 3.7 percent of the hospitalizations. The proportion of adverse events attributable to errors (i.e., preventable adverse events)
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From page 31... ...
In a study of 815 consecutive patients on a general medical service of a university hospital, it was found that 36 percent had an iatrogenic illness, defined as any illness that resulted from a diagnostic procedure, from any form of therapy, or from a harmful occurrence that was not a natural consequence of the patient's disease.40 Of the 815 patients, nine percent had an iatrogenic illness that threatened life or produced considerable disability, and for another two percent, iatrogenic illness was believed to contribute to the death of the patient. In a study of 1,047 patients admitted to two intensive care units and one surgical unit at a large teaching hospital, 480 (45.8 percent)
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From page 32... ...
pharmacies at an estimated cost of about $92 billion.52 An estimated 3.75 billion drug administrations were made to patients in hospitals.53 In a review of U.S. death certificates between 1983 and 1993, it was found that 7,391 people died in 1993 from medication errors (accidental poisoning by drugs, medicaments, and biologicals that resulted from acknowledged errors by patients or medical personnel)
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From page 33... ...
In a study of prescribing errors detected and averted by pharmacists in a 631-bed tertiary care teaching hospital between July 1994 and June 1995, the estimated overall rate of errors was 3.99 per 1,000 medication orders.59 Children are at particular risk of medication errors, and as discussed below, this is attributable primarily to incorrect dosages.60 61 In a study of 101,022 medication orders at two children's teaching hospitals, a total of 479 errant medication orders were identified, of which 27 represented potentially lethal prescribing errors.62 The frequency of errors was similar at
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From page 34... ...
, the rate of preventable ADEs and preventable potential ADEs in ICUs was 19 events per 1,000 patient-days, nearly twice the rate of non-ICUs.64 When adjusted for the number of drugs used in the previous 24 hours or ordered since admission, there were no differences in error rates between ICUs and nonICUs. Current estimates of the incidence of medication errors are undoubtedly low because many errors go undocumented and unreported.65-68 For example, in a study of patients admitted to five patient care units at a tertiary care hospital during a six month period in 1993, it was found that incident reports were filed with the hospital's quality assurance program or called into the pharmacy hotline for only three of the 54 people experiencing an adverse drug event.69 Some errors are also difficult to detect in the absence of computerized surveillance systems.
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From page 35... ...
They include transfusion errors and adverse drug events; wrong-site surgery and surgical injuries; preventable suicides; restraint-related injuries or death; hospital-acquired or other treatment-related infections; and falls, burns, pressure ulcers, and mistaken identity. Leape et al.
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From page 36... ...
In hospitals, high error rates with serious consequences are most likely in intensive care units, operating rooms and emergency departments. Thomas et al., in their study of admissions to hospitals in Colorado and Utah experiencing adverse events, found that about 30 percent were attributable to negligence.77 The hospital location with the highest proportion of
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From page 37... ...
Dubois and Brook studied 49 preventable deaths from 12 hospitals, and found that for those who died of a myocardial infarction, preventable deaths reflected errors in management; for cerebrovascular accident, most deaths reflected errors in diagnosis; and for pneumonia, some deaths reflected errors in management and some reflected errors in diagnosis.78 In an analysis of 203 cardiac arrests at a teaching hospital, Bedell et al. found that of the half that might have been prevented, the most common causes of potentially preventable arrest were medication errors and toxic effects, and suboptimal response by physicians to clinical signs and symptoms.79 Studies of Medication Errors Ensuring appropriate medication use is a complex process involving multiple organizations and professionals from various disciplines; knowledge of drugs; timely access to accurate and complete patient information; and a series of interrelated decisions over a period of time.
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From page 38... ...
accounted for 15 admissions, of which five were judged to be due to error in prescription and another five judged to have been avoidable had appropriate measures been taken by prescribing physicians.82 In an analysis of 682 children admitted to a Congenital Heart Disease Center at a teaching hospital in the United Kingdom, 441 medication errors were reported by
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From page 39... ...
Bates et al.,87 in an analysis of more than 4,000 admissions to two tertiary care hospitals, found that about 28 percent of 247 adverse drug events were preventable and most of these resulted from errors that occurred at the stages of ordering and administration. Davis and Cohen88 in their review of the literature and other evidence on errors report an error rate of 12 percent to be common in the preparation and administration of medications in hospitals.
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. Physician computer order entry could have prevented 84 percent missing dose medication errors, 86 percent of potential adverse drug events, and 60 percent of preventable adverse drug events.
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From page 41... ...
One recent study conducted at two prestigious teaching hospitals found that almost two percent of admissions experienced a preventable ADE, resulting in an average increased length of stay of 4.6 days and an average increased hospital cost of nearly $4,700 per admission.103 This amounts to about $2.8 million annually for a 700-bed teaching hospital, and if these findings are generalizable, the increased hospital costs alone of preventable adverse drug events affecting inpatients are about $2 billion for the nation as a whole. In a matched case-control study of all patients admitted to a large teaching hospital from January 1990 through December 1993, it was found that adverse drug events complicated 2.43 admissions per 100.1°4 Controls were matched to cases on primary discharge diagnosis related group (DRG)
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In a public opinion poll conducted by Louis Harris & Associates for the National Patient Safety Foundation, the health care environment was perceived as "moderately safe" (rated 4.9 on a scale of one through seven where one is not safe at all and seven is very safe) .~09 Respondents viewed the health care environment as much safer than nuclear power or food handling, but somewhat less safe than airline travel or the work environment.
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From page 43... ...
The various accreditation and licensure programs for health care organizations and providers have been promoted as "Good Housekeeping Seals of Approval," yet they fail to provide adequate assurance of a safe environment. Reducing medical errors and improving patient safety are not an explicit focus of these processes.
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From page 44... ...
., et al. The Costs of Adverse Drug Events in Hospitalized Patients.
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From page 45... ...
Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I
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Preventable Adverse Drug Events in Hospitalized Patients: A Comparative Study of Intensive Care and General Care Units.
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From page 47... ...
. Systems Analysis of Adverse Drug Events.
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From page 48... ...
The Costs of Adverse Drug Events in Hospitalized Patients, op cit.
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