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Medical Errors

Medical Errors. Zheng Yan Advised by: Dr. Dan France. Background (Studies). Two large studies conducted by the Institute of Medicine (IOM) found that adverse events occurred in 2.9 to 3.7% of hospitalizations.

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Medical Errors

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  1. Medical Errors Zheng Yan Advised by: Dr. Dan France

  2. Background (Studies) • Two large studies conducted by the Institute of Medicine (IOM) found that adverse events occurred in 2.9 to 3.7% of hospitalizations. • “An adverse event is an injury caused by medical management rather than the underlying condition of the patient.” — Institute of Medicine

  3. Background (Studies) • In Colorado and Utah hospitals, 8.8% of the adverse events lead to death. • The data from the studies suggest that 44,000 - 98, 000 Americans die each year as a result of medical errors.

  4. Background (Cases) • 27 year-old patient with leukemia died after erroneous intrathecal administration of vincristine • Drug should have been given intravenously • 2 year old baby died from a lethal dose of sedative promethazine, instead of anti-convulsant phenobarbital • Mix of medications in zipper bag where drugs were kept, because drugs had similar names, and ampoules looked alike

  5. Problem • Medical errors average of 1.7 mistakes per patient per day in ICU (out of 200 patient-care activities) • Fourth most common cause of death in U.S.

  6. Objective • To determine how the amount of workload effects the stress level of the charge nurses in the ER • The higher the stress level the higher the probability of committing medical errors. • To create solutions that reduce the high workload and thus stress, which in turn reduces the occurrence of a medical errors

  7. Method • 180-minute observation periods (Real-time data collection using Palm Pilots) • Example of of an observation period. • ObservationDate CurrentTask TaskStart TaskStop • 9/18/2003 Direct Patient Care 9/18/2000 3:04:09 PM 9/18/2000 3:09:00 PM • 9/18/2003 Charting 9/18/2000 3:09:34 PM 9/18/2000 3:10:11 PM • 9/18/2003 Getting Old Records 9/18/2000 3:10:16 PM 9/18/2000 3:10:23 PM • 9/18/2003 Direct Patient Care 9/18/2000 3:11:03 PM 9/18/2000 3:11:29 PM

  8. Method (Cont.) • Categories • · Average time to complete tasks (continuous – minutes) • Without interruptions • With interruptions • · Steps traveled (walked) (odometer reading - continuous) • · Time in motion (minutes - continuous)

  9. Method (Cont.) • · Number of patients managed simultaneously (continuous) • · Total number of unique patients managed (continuous) • · Number of tasks performed (continuous) • · Average direct patient care time (minutes – continuous)

  10. Method (Cont.) • Compiled data used to pin point areas where the efficiency could be improve and strategies can be formed to target those areas. • Example: 10% patient, 40% paperwork, 10% consults • Suggestions: Improved informatics system to streamline the data entry and retrieval process --> more patient care time and less stress from paperwork

  11. Present Work • Finishing up Literature Review • Preliminary training with palm pilot for observations of charge nurses.

  12. Future Work • Data of ER charge nurses collected and analyzed. • Creation of strategies for improvement of human communication between nurses and doctors and medical computer systems to reduce level of medical errors .

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