This past week, Dr. Kim Sears from Queen’s School of Nursing, along with her colleagues from across Canada, O’Brien-Pallas, Stevens, and Murphy, published their findings on a Pan-Canadian study of medication errors in the paediatric hospital population. The results were published in the Journal of Pediatric Nursing1, and reported in this week’s National Post by reporter Tom Blackwell.2
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Dr. Sears is an Assistant Professor in the School of Nursing, Co-Director of our new Master of Science in Healthcare Quality, and Deputy Director/Patient Safety, Queen’s Joanna Briggs Collaboration.
Dr. Sears’ study revealed some alarming statistics. In a small sample of 18 hospital wards, she uncovered four deaths attributable to medication error. Over the three-month period of the study, which involved a questionnaire in which nursing staff reported medication errors or “near misses”, there were 372 errors or potential errors uncovered. “As well as the four deaths, 51 were graded as potentially lethal, 20 as serious, 112 as significant and 185 minimal.”2
Dr. Kim Sears
The finding of systematic medication-related errors in hospitals is of course, not new. The Institute of Medicine in the United States, shone a light on this problem with the seminal publication, To Err is Human.4 This landmark work reported that there were between 44,000 and 98,000 deaths in U.S. hospitals that are attributable to medication errors. There have been literally thousands of studies since, and more importantly, a systematic movement around the world, to minimize and mitigate medical error. Still, fourteen years later, Sears’ publication illustrates just how difficult this is, and underscores the fact that we still need to be vigilant and attentive to medical error with virtually everything we, as health professional clinicians, do.
If you have any comments on patient safety issues in general, or medication errors in specific, please respond to this blog, or better yet…please drop by the Macklem House, my door is always open.
Richard
1. Sears K, O’Brien-Pallas L, Stevens B, Murphy GT. The Relationship Between the Nursing Work Environment and the Occurrence of Reported Paediatric Medication Administration Errors: A Pan Canadian Study. J of Pediatric Nursing. Published on line, 04 January 2013.
2. Tom Blackwell, National Post, http://news.nationalpost.com/2013/01/11/thats-four-children-who-died-hospital-drug-errors-blamed-for-child-deaths-in-new-report/
3. http://www.google.ca/imgres?imgurl=http://www.aafp.org/fpm/2007/0200/fpm20070200p41-uf1.jpg&imgrefurl=http://www.aafp.org/fpm/2007/0200/p41.html&usg=__FnA0w7Wk6sbVFGCbMdRw4llUAW8=&h=270&w=210&sz=26&hl=en&start=6&sig2=L0vLW2mVvPE3J0gknOnlFQ&zoom=1&tbnid=3WK2MCYJ506rFM:&tbnh=113&tbnw=88&ei=ZQTzUMbJONCcrQGOqIGgDg&prev=/search%3Fq%3Dmedication%2Berror%26um%3D1%26hl%3Den%26sa%3DN%26gbv%3
D2%26tbm%3Disch&um=1&itbs=1
4. http://iom.edu/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx
As a Pediatric Emergency Medicine Physician this story is very disturbing yet unfortunately has plagued medicine and in particular the field of pediatrics. The concerning portion, however, is that these deaths and mishaps ocurred in the non-emergent setting where time and stress are minimized to some extent. I have spent my career focusing on medical errors in the emergent setting, where seconds count and the difference between life and death depends on the success of the team. Systems that work are imperative as are the practice sessions required to perfect the choreographed dance of pediatric resuscitation.
Dear Peter
Thanks for your comment. I agree that an never ending focus on patient safety starts with establishing, refining and practicing all of the requisite competences.
Richard
People at University Health Network in Toronto, headed by Dr Joseph Fisher, developed a device, the Duocheck, that eliminates (zero errors in more than 300,000 uses as of April 2012) drug administration errors in the OR.
UHN has now ‘obtained’ the device from the developers but I have no information about its availability.
Declaration: I am a shareholder in Thornhill Research Inc., the company under whose aegis the Duocheck was developed.
Steve,
Thanks for mentioning this. I agree with the inference, that we should more widely deploy technology to assist us with mitigation of medical error.
Richard
Dear Richard:
Thanks for highlighting this important systems problem. The Electronic health record with electronic physician order entry provides real time dose and indication guidance for MDs adn RNs and eliminates issues of abbreviations, legibility etc. Establishing such as system in our region is an essential step in reducing medication errors. The culture of quality which I know you and the hospitals are partnering on fostering, through the SEAMO reward for Departmental Quality committee, should also help.
Thanks-Stephen Archer, Head of Medicine
Thanks Stephen,
I agree that an EMR/Medication Order Entry System is essential and should be a Canadian hospital standard.
Richard