PREVENTION OF ERRORS IN HEALTH CARE- PATIENT (MEDICAL CUSTOMER) SAFETY
Keywords:
Health Care, Preventable Medical Errors, Preventable Deaths, Patient (Medical Customer), Medical Customer Safety
Abstract
We are all painfully aware of the problem of patient safety in health care. More specifically is the growing number of preventable deaths that occur in our nation’s hospitals at an alarming rate. By Patient Safety, we mean the prevention of harm to patients while receiving Health Care. Medical errors not only result in additional costs for hospitalization, litigation, hospital-acquired infections, lost income and disability, etc, but they also cause erosion of trust, confidence, and satisfaction among the public and Health care providers.2 Patient Safety is the prevention of harm to patients. It is about eliminating preventable medical mistakes. Medical errors are common throughout the healthcare system and result in significant morbidity and mortality. Medical-related incidents are a common form of reported medical errors. In theory, they should never occur. These mistakes are also called “Never events”. Some of these are avoidable and preventable events. 50% of these mistakes are preventable. Some US estimates there are over 200,000 preventable deaths. This may be a conservative guess as other studies have put preventable deaths at over 400,000 annually according to James et al.
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References
1. Inaugural Address by DGHS... National Consultation Workshop on Patient Safety 10th to 12th May 2010 At Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Luck now.
2. James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf 2013; 9(3):122–128.
3. Pratap.c.reddy: International Congress on patient safety best practices in Asia –welcome to 5th patient safety congress: | The Lalit Ashok Bangalore | India. Inaugural address. October 16-17th 2015
4. Kounteya Sinha 'India records 5.2 million medical injuries a year ‘The Times of India- the author has posted comments on this article, TNN | Sep 21, 2013, 05.55 AM IST.
5. GBD 2013 Mortality and Causes of Death, Collaborators (17 December 2014). "Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.".Lancet. doi:10.1016/S0140-6736(14)61682-2. PMID 25530442.
6. Institute of Medicine (2000). "To Err Is Human: Building a Safer Health System (2000)". The National Academies Press. Retrieved2006-06-20.
7. Charatan, Fred (2000). "Clinton acts to reduce medical mistakes". BMJ Publishing Group. doi:10.1136/bmj.320.7235.597. Retrieved2006-03-17.
8. Weingart SN, Wilson RM, Gibberd RW, Harrison B; Wilson; Gibberd; Harrison (March 2000). "Epidemiology of medical error".BMJ 320 (7237): 774–7. doi:10.1136/bmj.320.7237.774.PMC 1117772. PMID 10720365.
9. Hayward RA, Heisler M, Adams J, Dudley RA, Hofer TP; Heisler; Adams; Dudley; Hofer (August 2007). "Overestimating outcome rates: statistical estimation when reliability is suboptimal". Health Serv Res42 (4): 1718–38. doi:10.1111/j.1475-6773.2006.00661.x.PMC 1955272. PMID 17610445.
10. Hayward R, Hofer T; Hofer (2001). "Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer".JAMA 286 (4): 415–20. doi:10.1001/jama.286.4.415.PMID 11466119.
11. "Medication Errors Injure 1.5 Million People and Cost Billions of Dollars Annually". The National Academy of Science. 2006. Retrieved 2006.
12. Leape LL (1994). "Error in medicine". JAMA 272 (23): 1851–7.doi:10.1001/jama.272.23.1851. PMID 7503827.
13. Patient Safety Movement website. Available at: http:// patientsafetymovement.org/ Accessed Jan. 2, 2014
14. R. P. Mahajan, Medication errors: can we prevent them? Oxford Journals Medicine & Health BJA Volume 107, Issue 1 Pp. 3-5.
15. Inaugural Address by DGHS. National Consultation Workshop on Patient Safety 10th to 12th May 2010 At Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow
16. A nationwide comprehensive study (2002-2004) CLEAN Program Evaluation Network (IPEN) for the Department of Family Welfare, Ministry of Health & Family Welfare.
17. J. Cranshaw1, K. J. Gupta2 and T. M. Cook3 Anaesthesia Litigation related to drug errors in anesthesia: an analysis of claims against the NHS in England 1995–2007; Anaesthesia, Volume 64, Issue 12, pages 1317–1323, December 2009
18. Glavin RJ, Drug errors: consequences, mechanisms, and avoidance. Br J Anaesth 2010;105:76-82. doi:10.1093/bja/aeq131.
19. Cooper JB, Newbower RS, Long CD, McPeek B. Preventable anesthesia mishaps: a study of human factors. Anesthesiology 1978;49:399-406.
20. Krahenbuhl MA, Schlienger R, Lampert M, Haschke M, Drewe J, Krahenbuhl. S. Drug related problems in hospitals: a review of the recent literature. Drug Saf 2007;30:379-407.
21. Merry AF, Peck DJ Anaesthetists, errors in drug administration and law.N Z Med J 1995;108:185-
22. Rothschild JM, Landrigan CP, Cronin JW, et al, The critical care safety study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med 2005;33:1694-700.
23. WHO: Millions Of People Die Each Year Due To Medical Errors :redOrbit: Fri, 22 Jul 2011.
24. Mahajan RP. Critical incident reporting and learning. Br J Anaesth 2010;105:69-75.
25. U.S. Food and Drug Administration. "Strategies to reduce medication errors."2005.
26. Gopal Reddy. N. Medication Errors In Anesthesia And Critical Care.DOI: 10.14260/jemds/2015/371 / Vol. 4/ Issue 15/ Feb 19, 2015 Page 2566- 2574
27. Webster CS et al. The frequency and nature of drug administration error during anesthesia. Anesth Int Care 2001; 29:494–500.
28. Cousins D, Gerrett D, Warner B. A review of medication incidents reported to the National Reporting and Learning System in England over six years (2005–2010). Br J Clin Pharmacol, 22 December 2011. Accepted article: doi: 10.1111/j.1365-2125.2011.04166.x. (Epub ahead of print).
29. Neale, G; Woloshynowych, M; Vincent, C (July 2001). "Exploring the causes of adverse events in NHS hospital practice". Journal of the Royal Society of Medicine 94(7): 322–30.
30. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH (2002). "Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction". JAMA 288 (16): 1987–93.
31. Gardner, Amanda (6 March 2007). "Medication Errors During Surgeries Particularly Dangerous". The Washington Post.
32. 8th Annual MEDMARX Report (2008-01-29). "Press Release". U.S. Pharmacopeia.
33. McDonald, MD, Clement J. (4 April 2006). "Computerization Can Create Safety Hazards: A Bar-Coding Near Miss". Annals of Internal Medicine 144 (7): 510–516.
34. US Agency for Healthcare Research & Quality (2008-01-09). "Physicians Want To Learn from Medical Mistakes but Say Current Error-reporting Systems Are Inadequate". Retrieved 2011-03-23.
35. Michaels, Robert K. MD, MPH; Makary, Martin A. MD, MPH†; Dahab, Yasser MD*; Frassica, Frank J. MD; Heitmiller, Eugenie MD; Rowen, Lisa C. RN, dnsc§; Crotreau, Richard MD; Brem, Henry MD; Pronovost. Achieving the National Quality Forum's “Never Events”: Prevention of Wrong Site, Wrong Procedure, and Wrong Patient Operations. Ann surgery. April2007,24(4).
36. Narra Gopal Reddy. Preventable Errors: Never Events. Journal of Evolution of Medical and Dental Sciences 2014; Vol. 3, Issue 29, July 21; Page: 8162-8172, DOI: 10.14260/jemds/2014/3027.
2. James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf 2013; 9(3):122–128.
3. Pratap.c.reddy: International Congress on patient safety best practices in Asia –welcome to 5th patient safety congress: | The Lalit Ashok Bangalore | India. Inaugural address. October 16-17th 2015
4. Kounteya Sinha 'India records 5.2 million medical injuries a year ‘The Times of India- the author has posted comments on this article, TNN | Sep 21, 2013, 05.55 AM IST.
5. GBD 2013 Mortality and Causes of Death, Collaborators (17 December 2014). "Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.".Lancet. doi:10.1016/S0140-6736(14)61682-2. PMID 25530442.
6. Institute of Medicine (2000). "To Err Is Human: Building a Safer Health System (2000)". The National Academies Press. Retrieved2006-06-20.
7. Charatan, Fred (2000). "Clinton acts to reduce medical mistakes". BMJ Publishing Group. doi:10.1136/bmj.320.7235.597. Retrieved2006-03-17.
8. Weingart SN, Wilson RM, Gibberd RW, Harrison B; Wilson; Gibberd; Harrison (March 2000). "Epidemiology of medical error".BMJ 320 (7237): 774–7. doi:10.1136/bmj.320.7237.774.PMC 1117772. PMID 10720365.
9. Hayward RA, Heisler M, Adams J, Dudley RA, Hofer TP; Heisler; Adams; Dudley; Hofer (August 2007). "Overestimating outcome rates: statistical estimation when reliability is suboptimal". Health Serv Res42 (4): 1718–38. doi:10.1111/j.1475-6773.2006.00661.x.PMC 1955272. PMID 17610445.
10. Hayward R, Hofer T; Hofer (2001). "Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer".JAMA 286 (4): 415–20. doi:10.1001/jama.286.4.415.PMID 11466119.
11. "Medication Errors Injure 1.5 Million People and Cost Billions of Dollars Annually". The National Academy of Science. 2006. Retrieved 2006.
12. Leape LL (1994). "Error in medicine". JAMA 272 (23): 1851–7.doi:10.1001/jama.272.23.1851. PMID 7503827.
13. Patient Safety Movement website. Available at: http:// patientsafetymovement.org/ Accessed Jan. 2, 2014
14. R. P. Mahajan, Medication errors: can we prevent them? Oxford Journals Medicine & Health BJA Volume 107, Issue 1 Pp. 3-5.
15. Inaugural Address by DGHS. National Consultation Workshop on Patient Safety 10th to 12th May 2010 At Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow
16. A nationwide comprehensive study (2002-2004) CLEAN Program Evaluation Network (IPEN) for the Department of Family Welfare, Ministry of Health & Family Welfare.
17. J. Cranshaw1, K. J. Gupta2 and T. M. Cook3 Anaesthesia Litigation related to drug errors in anesthesia: an analysis of claims against the NHS in England 1995–2007; Anaesthesia, Volume 64, Issue 12, pages 1317–1323, December 2009
18. Glavin RJ, Drug errors: consequences, mechanisms, and avoidance. Br J Anaesth 2010;105:76-82. doi:10.1093/bja/aeq131.
19. Cooper JB, Newbower RS, Long CD, McPeek B. Preventable anesthesia mishaps: a study of human factors. Anesthesiology 1978;49:399-406.
20. Krahenbuhl MA, Schlienger R, Lampert M, Haschke M, Drewe J, Krahenbuhl. S. Drug related problems in hospitals: a review of the recent literature. Drug Saf 2007;30:379-407.
21. Merry AF, Peck DJ Anaesthetists, errors in drug administration and law.N Z Med J 1995;108:185-
22. Rothschild JM, Landrigan CP, Cronin JW, et al, The critical care safety study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med 2005;33:1694-700.
23. WHO: Millions Of People Die Each Year Due To Medical Errors :redOrbit: Fri, 22 Jul 2011.
24. Mahajan RP. Critical incident reporting and learning. Br J Anaesth 2010;105:69-75.
25. U.S. Food and Drug Administration. "Strategies to reduce medication errors."2005.
26. Gopal Reddy. N. Medication Errors In Anesthesia And Critical Care.DOI: 10.14260/jemds/2015/371 / Vol. 4/ Issue 15/ Feb 19, 2015 Page 2566- 2574
27. Webster CS et al. The frequency and nature of drug administration error during anesthesia. Anesth Int Care 2001; 29:494–500.
28. Cousins D, Gerrett D, Warner B. A review of medication incidents reported to the National Reporting and Learning System in England over six years (2005–2010). Br J Clin Pharmacol, 22 December 2011. Accepted article: doi: 10.1111/j.1365-2125.2011.04166.x. (Epub ahead of print).
29. Neale, G; Woloshynowych, M; Vincent, C (July 2001). "Exploring the causes of adverse events in NHS hospital practice". Journal of the Royal Society of Medicine 94(7): 322–30.
30. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH (2002). "Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction". JAMA 288 (16): 1987–93.
31. Gardner, Amanda (6 March 2007). "Medication Errors During Surgeries Particularly Dangerous". The Washington Post.
32. 8th Annual MEDMARX Report (2008-01-29). "Press Release". U.S. Pharmacopeia.
33. McDonald, MD, Clement J. (4 April 2006). "Computerization Can Create Safety Hazards: A Bar-Coding Near Miss". Annals of Internal Medicine 144 (7): 510–516.
34. US Agency for Healthcare Research & Quality (2008-01-09). "Physicians Want To Learn from Medical Mistakes but Say Current Error-reporting Systems Are Inadequate". Retrieved 2011-03-23.
35. Michaels, Robert K. MD, MPH; Makary, Martin A. MD, MPH†; Dahab, Yasser MD*; Frassica, Frank J. MD; Heitmiller, Eugenie MD; Rowen, Lisa C. RN, dnsc§; Crotreau, Richard MD; Brem, Henry MD; Pronovost. Achieving the National Quality Forum's “Never Events”: Prevention of Wrong Site, Wrong Procedure, and Wrong Patient Operations. Ann surgery. April2007,24(4).
36. Narra Gopal Reddy. Preventable Errors: Never Events. Journal of Evolution of Medical and Dental Sciences 2014; Vol. 3, Issue 29, July 21; Page: 8162-8172, DOI: 10.14260/jemds/2014/3027.
How to Cite
1.
Reddy NG. PREVENTION OF ERRORS IN HEALTH CARE- PATIENT (MEDICAL CUSTOMER) SAFETY. Med. res. chronicles [Internet]. 2015May29 [cited 2024May4];2(3):371-83. Available from: https://medrech.com/index.php/medrech/article/view/96
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Review Article
