1. Medical Mistakes
AN APPROACH FOR TRACKING AND REDUCING HOSPITAL ERRORS
By Terry Coulon
HSM 542
S

2. HIGHLIGHTS
S Introduction to common Hospital and medication Errors
S IOM’s impact on tracking and reducing hospital errors
S The Pro’s and Con’s of the IOM’s Recommendations
S An alternative plan for reducing and tracking hospital
errors
S Alternative plan’s impact on hospital errors and it’s
sustainability

3. What’s a Medical/Medication
Error
S A Medical Error is a preventable adverse effect of
care, whether or not it is evident or harmful to the patient. This
might include an inaccurate or incomplete diagnosis or
treatment of a disease, injury, syndrome behavior, infection, or
other ailment.
S A Medication Error is any incorrect or wrongful administration
of a medication, such as a mistake in dosage or route of
administration, failure to prescribe or administer the correct
drug or formulation for a particular disease or condition, use of
outdated drugs, failure to observe the correct time for
administration of the drug, or lack of awareness of adverse
effects of certain drug combinations

4. Common medical and
medication Errors
S
Common medical errors that
take’s place within today’s
hospitals are:
S
Common medication errors that
takes place within today’s
hospitals are:
S
Diagnostic errors
S
Ordering errors
S
Treatment and prevention errors
S
Transcribing errors
S
Miscellaneous errors (i.e.
communication, equipment and
systemic failures).
S
Dispensing errors
S
Administrating errors
S
Monitoring errors

5. IOM TO THE RESCUE
???
S

6. The IOM’s Contribution
S The Institute of Medicine (IOM) is an independent, nonprofit
organization that works outside of government to provide
unbiased and authoritative advice to decision makers and the
public.
S In 1999, IOM published a research report titled “To Err is
Human: Building a Safer Health System “
S The report was used to help formulate four specific
recommendations for tracking and diminishing errors within a
hospital setting.

7. Idea’s for addressing hospital
Errors
S
1st RECCOMENDATION
S
2ND RECCOMENDATION
creating a center for patient
safety within the agency for
healthcare Research and
Quality.
S 3RD RECCOMENDATION
S
The establishment of
mandatory and voluntary
reporting systems.
S
4th RECCOMENDATION
S
S
Creating safety systems inside
healthcare organizations through
safe practice implementations’ at
the delivery level of care.
S
Raise standards for
improvement in safety through
the actions and oversight of
organizations, group
purchasers and professional
groups

8. Did the IOM Succeed?
S Five years since these recommendations were entertained by
the U.S. Congress for proposed implementation at the federal
level, the rate of medical and medication errors has remained
relatively “high”
S Extensive research performed in 2004 year suggested that
medical errors still remained high, including several issues
regarding substandard patient care with errors
S The IOM failed to fulfill its expectations of a 50% reduction in
medical/medication errors based upon the institute's
recommendations.

9. Why did the IOM Fail?
PROS
S
The creation of center for
patient safety within the agency
was realized.
S
IOM’s 4th recommendation has
sparked the evolution of
technology advanced health
safety systems (I.E. Health IT
systems).
CONS
S
Compliance with mandatory and
voluntary reporting systems has
been inconsistent due to
physician's fears of malpractice
lawsuits and financial penalties.
S
Business groups such as
“Leapfrog” have designed tools
that inaccurately capture hospital
error costs.
S
Newly developed Health safety IT
systems have added to medical
errors within many hospitals.

10. Hospital Errors are still a
problem
Medical Error Mortality
rate of 2004
Medical Error Mortality
rate of 2012
S
195,000 Americans died as a
result of preventable errors .
S
134,000 Americans died as a
result of preventable errors.
S
Overall costs attributable to
hospital errors was around $25
billion.
S
Overall costs attributable to
hospital errors was $19.5
billion.
S
Bed sores, failure to
rescue, and post-operative
respiratory failure were the
most common errors.
S
Patient
misidentifications, medical
equipment misuse and
misdiagnosis were the most
common errors.

11. Numbers Don’t Lie
2012 Incident report
12%
63%
25%
63%
clinical process
staff behavior
medications

12. IS THERE AN
ALTERNATIVE???
“To reduce the amount of hospital
errors, a more comprehensive
approach is needed”
~ FDA
S

13. All Hands on Deck
S
The “All Hands on Deck” Patient Safety plan is a four part collaborative
plan involving the IOM, state legislatures, the Food and Drug
Administration and the Department of Health and Human Services. The
plan is as follows:
S
A team of adverse medical event researchers and analysts, affiliated with
the IOM, will be acquiring all relevant medical and medication error data
(i.e Inpatient, Outpatient and Ambulatory).
S
California’s “Voluntary reporting bill” will be presented to all other
state’s legislature in an effort to implement this version of the bill to
increase physician error reporting.
S
Health business groups with proposed calculating cost tools for hospital
errors will go through a Health business oversight and regulatory
committee as an extension of HHS (Health and Human Services)
department.
S
Proposed health IT systems and tools shall go through the “risk-based
regulatory framework” headed by the FDA for approval to ensure it’s

14. Benefits and Drawbacks
Benefits
Drawbacks
S
S
It’s a comprehensive effort at
the state and federal level to
exclusively target and reduce
hospital errors.
S
The plan doesn’t take into
account nursing and retirement
home errors.
S
“Cash Strapped” hospital
budgets might stop the plan’s full
implementation.
S
S
The plan hinges on U.S.
Congressional approval for
complete operation and
implementation.
The plan’s costs is a little under
a $1 million dollars to operate.
It broadens the scope of Health
regulatory agencies involving
the public’s health and well
being.

15. Is there a “Backup Plan”
S If Congress rejects “All Hands on Deck”, a contingency plan for
targeting and reducing hospital errors will follow.
S
The plan will consist of representative’s from the IOM visiting only those
hospitals ranked “High” on the mixed method analysis; where information
and training sessions will be held on monthly basis.
S
sessions will give patients, physician and other allied health professionals
information regarding their hospital’s error rates and ways in which these
error rates can be improved.
S
This plan will be of “no charge” to the hospital and patients that sign up.

16. “All Hands on Deck” is Worth
It!!!
S
In order to effectively impact the rise and cost of medical errors to
healthcare, we need a collective effort at the state and federal level.
S
If hospitals want to attract more patients, developing a culture of
patient safety would be in their best interest towards achieving a
quality of care standard that separates them from the competition.
S
While this plan leaves out the reduction of medical errors in nursing
homes, a significant majority of medical errors within hospitals are
researched, evaluated and regulated under this collaborative effort.

17. QUESTIONS???

18. References
S
The Institute of Medicine. (2013). Medical errors and the Institute of Medicine (IOM). Premier: Transforming
Healthcare together. Premier, Inc. https://www.premierinc.com/safety/topics/patient_safety/index_1.jsp
S
Agency for Healthcare Research and Quality (AHRQ) (20130). Voluntary Patient Safety Event Reporting (Incident
Reporting). Department of Health and Human Services. http://www.psnet.ahrq.gov/primer.aspx?primerID=13
S
Gideon, G. (2010). Medical Errors tied to patient transfers. White Coat Notes: News from the Boston Area medical
community. http://www.boston.com/news/health/blog/2010/10/medical_errors.html?rss_id=Most+Popular
S
U.S. news and world report. (2010). Cost of medical malpractice tops $55 billion a year in the U.S. USN Health
Day. http://health.usnews.com/health-news/managing-your-healthcare/healthcare/articles/2010/09/07/cost-ofmedical-malpractice-tops-55-billion-a-year-in-us
S
Binder, L. (2013). Leapfrog defends methodology. Modern Healthcare, 43(32), 24.
S
Foster, N. (2013). Leapfrog tool 'seriously flawed'. Modern Healthcare, 43(31), 16.
S
Conn, J. (2013). Targeting adverse events. Modern Healthcare, 43(27), 10.
S
Lentz, R. (2001). Quiet Report. Modern Physician, 5(9), 2.
S
Bleich, S. (2005). Medical Errors: Five Years After the IOM Report. The commonwealth fund