Clinical errors - their causes and frequency in hospitals Prof Johanna Westbrook

1. Clinical errors - their causes and frequency in hospitals Prof Johanna Westbrook Prof Enrico Coiera Funded by: HCF Health & Medical Research Foundation

2. Problem • High rates of medical errors and adverse events • 16% of admissions in Aust experience an adverse event • 51% of these were judged to be preventable • Cost in additional bed-days alone of these errors is estimated at 5% of the health budget. (Quality in Australian Health Care Study, Wilson et al., 1995)

3. Medication Errors • In Australia 2% inpatients experience harm or death due to medication errors • Estimated errors in 20% of all drug doses administered in hospital • IV medications have error rates of 50-90% • Only 1 Australian study – 20% error rate in IVs 2 surgical wards

4. Communication load • High communication loads • 80% of time in communication • Interrupted on average 15/hour

5. Percentage of time nurses spent in different work tasks (N=244 hours of observation)

6. Which clinical task is most likely to be interrupted? • 25% of all interruptions occurred while nurses were preparing or administering medications

7. Interruptions add to cognitive load, stress and reduce decision-making performance Errors

8. Aim • To examine the relationships between clinicians’ cognitive & communication loads and two types of errors: • Medication administration errors • Task scheduling errors eg forget tasks, task completion delayed or incomplete

9. Hypotheses • Being interrupted while preparing or administering a drug increases the likelihood of a medication error • Interruptions & multi-tasking in high stress clinical environments increase task scheduling errors (ie tasks are left incomplete, delayed or forgotten) • Clinical experience may compensate for the effects of a high communication load

10. Medication Administration Errors • Watch nurses as they prepare & administer IV medications • Record interruptions • Compare observed data with patients’ charts to identify errors

13. Follow Drs for 2hr blocks and record: Work tasks Interruptions Multi-tasking Ask about What tasks next? How stressed? Drs observation study

14. Outcomes • Rates & type of IV medication administration errors • Determine relationship between interruptions and medication errors • By error type and nurse experience • Measure association of cognitive and communication load and task scheduling errors • Eg Average time taken to return to interrupted tasks • Recovery from interruptions by clinician experience

15. Importance • Baseline data to test any interventions designed to reduce medication errors • New data about clinicians’ communication loads and errors, first step in designing effective interventions to support clinicians’ work. • Establishing links between researchers & health insurance industry