patient safety errors 2013 report

How many patients are harmed by medical errors?

Globally, as many as 4 in 10 patients are harmed in primary and outpatient health care. Up to 80% of harm is preventable. The most detrimental errors are related to diagnosis, prescription and the use of medicines (6).

Should health professionals be rewarded for reporting errors during healthcare?

Several studies have documented that health professionals who are rewarded and motivated for reporting errors during healthcare are encouraged to further improve on their reporting behaviour which subsequently improves patient safety in the organisation [22, 43].

What is the easiest error to detect in medical records?

The easiest error to detect in medical records is an error of commission. This occurs when a mistaken action harms a patient either because it was the wrong action or it was the right action but performed improperly.

What are some of the patient safety situations causing most concern?

Below are some of the patient safety situations causing most concern. Medication errors are a leading cause of injury and avoidable harm in health care systems: globally, the cost associated with medication errors has been estimated at US$ 42 billion annually (10).

What are the top 5 medical errors?

Eight common medical errors that harm patients are:Diagnostic Errors and Mistakes. ... Medication Errors. ... Surgical Errors. ... Labor and Delivery Errors. ... Anesthesia Errors. ... Failure to Obtain Informed Consent. ... Communication Errors. ... Infections and Secondary Complications.

What are patient safety errors?

Errors occur mostly during the prescription, preparation, and administration of medical drugs (10). Errors are often due to mistaking patient or procedures, miscalculation, writing mistakes, reading mistakes, mishearing, or reaching for the wrong substance.

What is the most common error in patient care?

Most Common Preventable Medical ErrorsMisdiagnosis. The wrong diagnosis can prove catastrophic to a patient in serious need of medical intervention. ... Medication Error. ... Faulty Medical Devices. ... Infection. ... Failure To Account For Surgical Equipment. ... Improper Medical Device Placement.

What is the process for reporting errors in patient care?

There are several steps to appropriately dealing with a medical error that are relatively straightforward:Let the patient and family know. ... Notify the rest of the care team. ... Document the error and report it to the hospital safety committee.

What are 2 common medical errors related to patient safety?

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.

What is the most common cause of errors in any health care setting?

Communication Problems Communication breakdowns are the most common causes of medical errors. Whether verbal or written, these issues can arise in a medical practice or a healthcare system and can occur between a physician, nurse, healthcare team member, or patient. Poor communication often results in medical errors.

What are some examples of clinical errors?

[1] Among the problems that commonly occur during providing health care are adverse drug events and improper transfusions, misdiagnosis, under and over treatment, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities.

What are 5 different safety concerns in a healthcare setting?

The 10 patient safety concerns every health care worker needs to know aboutMedication errors. ... Diagnostic errors. ... Patient discharge errors. ... Workplace safety issues. ... Aging hospital facility issues. ... Reprocessing issues. ... Sepsis. ... "Super" superbugs.More items...

What are 5 common causes of medication errors?

Common causes of medication error include incorrect diagnosis, prescribing errors, dose miscalculations, poor drug distribution practices, drug and drug device related problems, incorrect drug administration, failed communication and lack of patient education.

How do you document medical errors?

Disclosing medical errors the right wayBegin by stating there has been an error;Describe the course of events, using nontechnical language;State the nature of the mistake, consequences, and corrective action;Express personal regret and apologize;Elicit questions or concerns and address them; and.More items...

What is an error reporting system?

The MER program is a voluntary medication error reporting system originated by the Institute for Safe Medication Practice (ISMP) in 1975 and administered today by U.S. Pharmacopeia (USP). The MER program receives reports from frontline practitioners via mail, telephone, or the Internet.

Should medical errors be reported?

Since reporting both errors and near misses has been key for many industries to improve safety,6 health care organizations and the patients they serve can benefit from enabling reporting. Reporting sets up a process so that errors and near misses can be communicated to key stakeholders.

Summary

Preliminary estimates for 2013 show a further 9 percent decline in the rate of hospital-acquired conditions (HACs) from 2012 to 2013, and a 17 percent decline, from 145 to 121 HACs per 1,000 discharges, from 2010 to 2013.

Introduction

Much attention has been focused on preventing patient harm since the Institute of Medicine's (IOM's) 1999 publication of To Err Is Human: Building a Safer Health System and its subsequent 2001 publication of Crossing the Quality Chasm: A New Health System for the 21st Century.

Results

Preliminary estimates for 2013 show that the national HAC rate declined by 9 percent from 2012 to 2013 and was 17 percent lower in 2013 than in 2010 ( Exhibit 2 ).

Discussion

The estimated 17 percent reduction in HACs from 2010 to 2013 indicates that hospitals have made substantial progress in improving safety. An estimated 1.3 million fewer harms were experienced by patients from 2010 to 2013 than would have occurred if the rate of harm had remained at the 2010 level.

Background

Patient safety is defined by the Canadian Patient Safety Institute (CPSI) as “the pursuit of the reduction and mitigation of unsafe acts within the healthcare system, as well as the use of best practices shown to lead to optimal patient outcomes”. 1 (p.43) It is important to note that not all adverse events are due to errors.

Inclusion criteria

Nursing students who are enrolled in either registered nursing (RN) programs or registered/licensed practical nursing programs (RPN/LPN), in any year of their nursing program, actively participating in a clinical placement will be considered in this review.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article.

Data extraction: charting the results

A draft charting table or form will be developed to record the key information of the source, such as author, reference and results or findings relevant to the review question (Appendix I). This may be further refined at the review stage and the charting table updated accordingly. Some key information that will be extracted includes

Presentation of the results

The results of a scoping review will be presented as a diagram or table of the data extracted from the included papers. The diagram or table will display the type or category of patient error (e.g. harm or near miss) and the number or errors tallied within the respective nursing programs (RN or RPN/LPN).

What is a lethal error of communication?

Errors of communication can occur between 2 or more providers or between providers and patient. One example of a lethal error of communication between provider and patient occurred when cardiologists failed to warn their 19-year-old patient not to run.

How many patients were treated in tertiary hospitals in 2004?

In a somewhat similar study published in March 2011 in the journal Health Affairs, investigators examined the medical records of 795 patients treated in 1 of 3 tertiary hospitals in the month of October 2004. 18 These hospitals had been recognized for their efforts to improve patient safety. The investigators also used the GTT to discover adverse ...

What is the 2 tier approach to medical records?

All studies used a 2-tier approach that consisted of screening of medical records by nonphysicians, usually nurses or pharmacists, to flag suspect events. In the second tier, physicians examined the suspect events to determine if a genuine adverse event had occurred and, if so, the level of seriousness of the event.

When was the OIG pilot study published?

A pilot study by the OIG was published in 2008 in an effort to explore the effectiveness of search methods for adverse events. 21 As noted in the methods section, this study relied on 5 search methods for flagging potential adverse events in medical records but did not specify whether such events were preventable.

What is preventability in a case?

The prevailing view is that “preventability” of an adverse event links to the commission of an identifiable error that caused an adverse event. Adverse events that cannot be traced to a likely error should not be called “preventable.”.