LEADING QUALITY INITIATIVES. DR. SAIRA ZAFAR ASSISSTANT PROFESSOR, DEPT OF MEDICINE PROFESSIONAL DEVELOPMENTAL SERIES FOR NEW PROFESSIONSL STAFF FEB, 15 TH 2013. Objectives. Definition of Adverse Events ( AEs) Prevalence, types and causes of medical errors
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DR. SAIRA ZAFAR
ASSISSTANT PROFESSOR, DEPT OF MEDICINE
PROFESSIONAL DEVELOPMENTAL SERIES
FOR NEW PROFESSIONSL STAFF
FEB, 15TH 2013
Mrs. W is an 87 year old who was admitted to the CTU with pneumonia. She was treated with levofloxacin. Her past history was significant for CAD and atrial fibrillation for which she was taking metoprolol, warfarin and vasotec.
As she was confused, her medication list was determined by an older list her husband provided from their pharmacy. Included in that list was digoxin, a drug that was discontinued three months prior to the admission due to bradycardia.. The patient was on metoprolol 12.5 mg BID at home but it was ordered as 25 mg BID by mistake.
Due to increased dose of metoprolol and the inadvertently added digoxin, Mrs. W developed complete heart block from which she was successfully resuscitated.
She developed Upper GI bleed. At the time, her INR was found to be 9 which was likely secondary to a drug-drug interaction between coumadin and the new antibiotic levofloxacin for which she was again appropriately treated.
She was found to have a creatinine of 200 mmol/L and potassium of 5.4mmol/L. Despite this, her vasotec was not held and no repeat blood work was done until day 9 when she was found to have a creatinine of 650 mmol/L and potassium of 7.2mmol/L. She subsequently had to undergo dialysis.
Institute of Medicine Land Mark Report:
To Err is Human: Building a Safer Health System: the National Academy of Science 2000.
CMAJ May 25, 2004 vol. 170 no 11
Analysis of Relative Risks and Levels of Risk in Canada, Ron Law Juderon associates
PLUS SOME BONUS REASONS
“ Team communication problems are the most frequently cited root cause in JACHO sentinel event statistics”.
“Sentinel events statistics, Sept 30, 2007,” Joint Commission on Accreditation of Healthcare Organizations
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Forster AJ, Murff HJ, Peterson JF, et al. Adverse drug events occurring following hospital discharge. J Gen Intern Med. 2005;20:317-323.
Cornish PL, Knowles SR,et al. Unintended Medication Discrepancies at the Time of Hospital Admission. Arch Intern Med. 2005;165:424-429.
Leape LL, Bates DW, Cullen DJ et al. Systems analysis of adverse drug events. JAMA. 1995;272:35–43.
Follow up and monitoring errors:
Avoidance of reliance on memory
Simplify and standardize the process:
Arora V, A model for building a standardized hand- off protocol. JtComm J Qual patient saf. 2006;32(11):646-55
Encourage error reporting and near-misses, and use them as opportunities to prevent future errors
Langley GL, Nolan KM, The improvement guide: A practical approach to enhancing organizational performance. 2009.