Toward Error Prevention

I was surprised when I read recently that observers who spent nine months at a large urban teaching hospital discovered that errors occurred in the care of more than 45 percent of patients and that 17.7 percent of patients had serious consequences of these errors, ranging from temporary physical disability to death. This study was conducted on two surgical intensive care units and a surgical ward and was reported by faculty at Chicago's Kent College of Law in the Feb. 1, 1997, issue of The Lancet. Interestingly, the highest proportion of the adverse events occurred in the monitoring and daily care of the patients and not in the surgery itself. The health care providers identified causes for slightly more than half of the errors: 37.5 percent were said to have been due to an individual's mistake; 15.6 percent were attributed to faulty interaction between staff (i.e. miscommunication); and 9.8 percent were caused by administrative deficiencies, such as failure to provide necessary equipment or to arrange adequate staffing.

A study from Brigham and Women's Hospital in the July 5, 1995 issue of JAMA reported:

There were 247 adverse drug events (ADEs) and 194 potential ADEs in two tertiary care hospitals over a 6 month period. The extrapolated event rates were 6.5 ADEs and 5.5 potential ADEs per 100 non-obstetrical admissions.

Of all ADEs, 1 percent were fatal (none preventable), 12 percent life-threatening, 30 percent serious and 57 percent significant.

Twenty-eight percent of the non-fatal events were judged preventable.

Of the life-threatening and serious ADEs, 42 percent were preventable, compared with 18 percent of the significant ADEs.

Preventable ADEs occurred predominately at the stages of ordering (56 percent) and administration (34 percent). Transcription (6 percent) and dispensing errors (4 percent) were less common. Errors were more likely to be caught if they occurred early in the process: 48 percent at the ordering stage vs. 0 percent at the administration stage.

To more effectively prevent medication errors, the medical community is taking tips from the aviation industry, which has a long tradition of analyzing accidents and errors to learn what changes are needed to prevent recurrences. Each time a commercial airliner crashes, for example, specialized teams make an effort to reconstruct and analyze the event to determine what went wrong. Often an accident is the end result of a chain of events that was set in motion by a faulty system design that triggered an error or made it difficult to detect.

And so at Stanford we are looking at a systems approach for preventing errors. The error "experts" tell us that it is far more effective to change the system to reduce the chance of the error occurring than it is to focus on the error itself.

The system approach has two objectives: to make it difficult for individuals to err and to institute some checks and balances to allow for early detection and correction of errors before damage occurs. This approach seems far more effective than the traditional approach of focusing on individuals and isolated episodes and then responding with training or punishment to improve performance.

One approach to error correction will be Physician Order Entry with the IDX computerized medical record, which we hope to roll out within the year. [See related story]. Physicians will enter their orders directly onto the computer, thus reducing the chances for error by limiting the number of steps, and hence, the points at which errors can occur. This will also eliminate errors that may have occurred from illegible handwriting on the order sheets. We hope to have some "smart" interactive programs with the pharmacy, which will allow for automatic warnings if standard doses are exceeded or if a potential drug interaction or allergic reaction is overlooked by the physician. Boston's Brigham and Women's Hospital saw serious medication errors with the potential for injury drop significantly after instituting a computerized physician order entry system (JAMA, Oct. 21, 1998).

And now is the time to heed the call to be proactive. The Quality Improvement Steering Committee would be interested in hearing from anyone who has an idea for a project that could help reduce errors and improve the quality of care. For example, the teams in one of our surgical services has proposed that patients mark the site of an anticipated incision to help reduce the possibility of operating at an incorrect site. (Thankfully, this is not a large problem at our institution).

If you have thoughts about a potential project, please contact me (650-723-5371 or by email).

President of the Medical Staff

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