Think your self-reported medication error rate tells the whole story?
Think again, says Lucian Leape, M.D., a retired surgeon and a professor at the Harvard School of Public Health.
In reviewing errors, Leape has found wide discrepancies between what hospitals think their error rates are and what those rates really are.
From incident reports, the rate was typically about two errors per 1,000 cases. A retrospective chart review yielded a rate of seven per 1,000. A computer screening method developed at Intermountain Health Care, Salt Lake City, uncovered a rate of 38 per 1,000. Daily chart review produced a rate of 65 per 1,000. And chart review combined with computer screening revealed roughly 100 errors per 1,000 cases.
"All of these numbers are suspect," Leape says. "What counts is the difference between the bottom and the top. If you are relying on incident reports, you are missing 95% of them."
Leape is one of the advance scouts of the healthcare quality-improvement movement. His corner of the frontier is adverse drug events and medication errors. Two weeks ago, he was spreading the word at the National Forum on Quality Improvement in Health Care in Orlando, Fla.
Normally, people who report their errors are punished. Therefore, they have a disincentive to come forward.
One nurse who attended an earlier lecture on the subject went back to her community hospital and told her staff that henceforth, no one would be punished for reported errors, Leape says. The rate immediately went up by a factor of 10.
Leape believes human error can be reduced by improving the systems in which people work.
Other recommendations include:
*Avoid relying too much on memory.
*Simplify processes. Complicated processes create more opportunities for error.
*Use forcing functions. You can't start your car in reverse anymore, because the manufacturers redesigned the ignition mechanism. Likewise, anesthesiologists can't confuse nitrous oxide and oxygen anymore, because the nozzles are no longer compatible.
*Use protocols and checklists wisely.