Johns Hopkins Medicine
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June 21, 2006
TRACKING COMPUTER-BASED ERROR REPORTS IMPROVES PATIENT SAFETY, HOPKINS STUDY FINDS
Physicians, nurses, pharmacists equally prone to fault
To err is human, but asking nurses, physicians and other hospital staff to report medication errors and log them into a computer database can help improve patient safety systems as well as human error rates, according to a study from the Johns Hopkins Children’s Center. Voluntary error-reporting systems are not new, but few studies have looked at the accuracy of the reporting and its impact, the Hopkins investigators say.
“Our goal was to explore the validity of this voluntary error-reporting system and whether front-line error-reporters were capturing the essence of the actual errors that occurred,” says author Marlene Miller, M.D., M.Sc., director of quality and safety initiatives for the Children’s Center. “There were some incorrect reports, but the overall trends were accurate, which allows us to say that this reporting system is a reliable index of problematic areas.” The findings are reported in the June issue of Quality & Safety in Healthcare.
Miller emphasizes that error data are valuable only if consistently monitored for patterns and used to create safety checks that prevent common errors from happening again.
“Error reporting is only as good as the actual changes that are made as a result of it,” says co-author Christoph Lehmann, M.D., director of clinical information technology at the Children’s Center. “Identifying and fixing potential medical errors is at the core of the Children’s Center patient safety program. Monitoring voluntary error reports has led to the creation of several programs that reduce and prevent medication errors.”
• A computerized ordering tool for pediatric chemotherapy that reduces medication errors in children undergoing cancer treatment.
• An online infusion calculator that reduces medication errors in children undergoing IV infusions.
• An online total parenteral nutrition (TPN) calculator, designed to prevent nutrition errors among premature babies in the neonatal intensive care unit, and currently used system-wide for all pediatric patients.
Since 2004, Johns Hopkins has implemented a hospital-wide computer reporting system that captures a variety of medication errors, the vast majority of which do not harm a patient but may have the potential to do so if systems are not corrected.
In the study, researchers found that errors occurred in every step of the medication process - from prescribing, to ordering to administering to the patient - and no one area is immune to errors. Physicians, nurses and pharmacists caring for children were equally prone to mistakes, researchers say.
“One of the more interesting findings was that drug-administering errors, such as giving the patient the wrong drug or the wrong dose or at the wrong time, were quite common,” Lehmann says. “We had focused in the past on ordering errors. This finding made us look for possible interventions on the administration side.”
Researchers reviewed data collected over 19 months via a voluntary error-reporting system that was in use at the Children’s Center from 2001 to 2004. They analyzed all 1,010 medication errors entered into the system between July 2001 and January 2003. Those who filed reports were asked to fill out an online form consisting of multiple choices and then submit a free-text description of the event. To determine the accuracy of the reports, researchers compared the multiple-choice form to the free-text description of the event, finding that the number of actual errors was 899, meaning that a slight over-reporting occurred. This was because certain errors were classified into more than one category. However, the overall distribution of errors by type was accurate.
Of the 1,010 originally reported errors, 173 (17 percent) were near-miss errors, which researchers describe as an error that didn’t harm the patient but would likely cause serious harm if it occurred again. A typical near-miss scenario would involve a physician prescribing the wrong dose, followed by a pharmacist dispensing the wrong dose, but a nurse catching the error before giving the wrong dose to the patient.
Of the 1,010, 38 percent (379 errors) did not reach the patient, half (511) reached the patient but no treatment or increased monitoring was required, 10 percent (103) reached the patient and required increased monitoring, 2 percent (17) reached the patient and required additional treatment or prolonged hospital stay. None was fatal or caused serious harm.
Nearly one-third were prescribing errors, one-quarter were dispensing errors, 38 percent were administering errors, and 8 percent were documentation errors. Half of all errors occurred in children under 6.
Most errors occurred with anti-infective medications, such as antibiotics or antivirals (17 percent), followed by pain relievers and sedatives (15 percent), antihistamines for allergies (15 percent), nutritional supplements and vitamins (11 percent), gastrointestinal medications (8 percent), cardiovascular medications (7 percent) and hormonal medications (6 percent).
Authors on the paper are Miller, Lehmann and John Clark, Pharm. D., of the Department of Pediatric Pharmacy.
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Founded in 1912 as the children’s hospital of the Johns Hopkins Medical Institutions, the Johns Hopkins Children’s Center offers one of the most comprehensive pediatric medical programs in the country, from performing emergency trauma surgery, to finding causes and treatments for childhood cancers, to delivering a child’s good bill of health. The Johns Hopkins Children Center’s Pediatric Trauma Service is Maryland’s only state-designated trauma center for children. With recognized Centers of Excellence in 20 pediatric subspecialties including cardiology, transplant, psychiatric illnesses and genetic disorders, Children’s Center physicians, nurses and staff provide compassionate care to more than 90,000 children each year. For more information, please visit: www.hopkinschildrens.org