Harmful medication errors, or preventable adverse drug events (ADEs), are a prominent quality and... more Harmful medication errors, or preventable adverse drug events (ADEs), are a prominent quality and cost issue in healthcare. Injectable medications are important therapeutic agents, but they are associated with a greater potential for serious harm than oral medications. The national burden of preventable ADEs associated with inpatient injectable medications and the associated medical professional liability (MPL) costs have not been previously described in the literature. To quantify the economic burden of preventable ADEs related to inpatient injectable medications in the United States. Medical error data (MedMarx 2009-2011) were utilized to derive the distribution of errors by injectable medication types. Hospital data (Premier 2010-2011) identified the numbers and the types of injections per hospitalization. US payer claims (2009-2010 MarketScan Commercial and Medicare 5% Sample) were used to calculate the incremental cost of ADEs by payer and by diagnosis-related group (DRG). The ...
Intravenous (IV) medications are vital in the management of hospitalized patients. Inpatients fre... more Intravenous (IV) medications are vital in the management of hospitalized patients. Inpatients frequently receive several IV medications concurrently, and these are commonly delivered with infusion pump systems. In particular, critically ill patients receive potent "high-alert" IV drugs, many with narrow safety margins requiring careful nursing titration. However, while intravenous medications have important benefits, errors associated with IV medication administration can result in severe or life-threatening adverse drug events (ADEs). Although errors in prescribing are often intercepted, administration errors do not get caught with most current systems While several safety improvements in IV infusion pump design have reduced mechanical complications, errors with IV drug administration such as incorrect programming persist. Intelligent IV infusion pumps have integrated software to provide point of care decision support (DS). This software includes drug library profiles con...
Research in the last decade has identified medication errors as a more frequent cause of unintend... more Research in the last decade has identified medication errors as a more frequent cause of unintended harm than was previously thought. Inpatient medication errors and error-prone medication usage are detected internally by medication error reporting and externally through hospital licensing and accreditation surveys. A hospital's rate of medication errors is one of several measures of patient safety available to staff. However, prospective patients and other interested parties must rely upon licensing and accreditation scores, along with varying access to outcome data, as their sole measures of patient safety. We have previously reported that much higher rates of medication errors were found when an independent audit was used compared with rates determined by the usual process of self-report. In this study, we summarize these earlier findings and then compare the error detection sensitivity of licensing and accreditation surveys with that of an independent audit. When experienced surveyors fail to detect a highly error prone medication usage system, it raises questions about the validity of survey scores as a measure of safety (i.e., lack of medication errors). Replication of our findings in other hospital settings is needed. We also recommend measures for improving patient safety by reducing error rates and increasing error detection.
Computerized physician order entry (CPOE) is an increasingly used technologic tool for entering c... more Computerized physician order entry (CPOE) is an increasingly used technologic tool for entering clinician orders, especially for medications and laboratory and diagnostic tests. Studies in hospitalized patients, including critically ill patients, have demonstrated that CPOE, especially with decision support, improves several outcomes. These improved outcomes include clinical measures such as reductions in serious medication errors and enhanced antimicrobial management of critically ill patients resulting in reduced length of stay. Additionally, several process outcomes have improved with CPOE such as increased compliance with evidence-based practices, reductions in unnecessary laboratory tests and cost savings in pharmacotherapeutics. Future studies are needed to demonstrate the benefits of more patient specific decision support interventions and the seamless integration of CPOE into a wireless, computerized medication administration system.
Journal of the American Medical Informatics Association : JAMIA, Jan 21, 2015
Failure to follow-up nonurgent, clinically significant test results (CSTRs) is an ambulatory pati... more Failure to follow-up nonurgent, clinically significant test results (CSTRs) is an ambulatory patient safety concern. Tools within electronic health records (EHRs) may facilitate test result acknowledgment, but their utility with regard to nonurgent CSTRs is unclear. We measured use of an acknowledgment tool by 146 primary care physicians (PCPs) at 13 network-affiliated practices that use the same EHR. We then surveyed PCPs to assess use of, satisfaction with, and desired enhancements to the acknowledgment tool. The rate of acknowledgment of non-urgent CSTRs by PCPs was 78%. Of 73 survey respondents, 72 reported taking one or more actions after reviewing a CSTR; fewer (40-75%) reported that using the acknowledgment tool was helpful for a specific purpose. Forty-six (64%) were satisfied with the tool. Both satisfied and nonsatisfied PCPs reported that enhancements linking acknowledgment to routine actions would be useful. EHR vendors should consider enhancements to acknowledgment func...
Joint Commission journal on quality and patient safety / Joint Commission Resources, 2005
Infusion devices can be programmed with individual hospitals' "best practice" rules... more Infusion devices can be programmed with individual hospitals' "best practice" rules for intravenous (i.v.) drug administration, and alerts can be provided if dosages fall outside pre-established limits. High variation levelsare common in medical care but can increase safety risk if the variation is unnecessary. The i.v. best practice data sets of drugs from 100 hospitals using one manufacturer's infusion devices were compared to assess the number of drug names used and thevariation in concentrations, dose units, dose limits, and administration practices. The 100 hospitals showed an average of 64 drugs per data set and an average of 113 different drug/concentration 4 combinations. On average, each hospital had designated 6 profiles or unique patient care areas; there were 4 different names per drug across the hospitals (for example, amiodarone had 45 different names). High levels of variation in concentrations were ubiquitous. Overall, 60% of medications had more th...
Critically ill patients require high-intensity care and may be at especially high risk of iatroge... more Critically ill patients require high-intensity care and may be at especially high risk of iatrogenic injury because they are severely ill. We sought to study the incidence and nature of adverse events and serious errors in the critical care setting. We conducted a prospective 1-year observational study. Incidents were collected with use of a multifaceted approach including direct continuous observation. Two physicians independently assessed incident type, severity, and preventability as well as systems-related and individual performance failures. Academic, tertiary-care urban hospital. Medical intensive care unit and coronary care unit patients. None. The primary outcomes of interest were the incidence and rates of adverse events and serious errors per 1000 patient-days. A total of 391 patients with 420 unit admissions were studied during 1490 patient-days. We found 120 adverse events in 79 patients (20.2%), including 66 (55%) nonpreventable and 54 (45%) preventable adverse events a...
Early warning criteria ("criteri... more Early warning criteria ("criteria"), used to activate rapid response system (RRS) teams, may improve patient outcomes by predicting life-threatening adverse events--urgent intensive care unit (ICU) transfers and cardiac arrests. We conducted a case-control study on medicine patients in an academic medical center from May 2005 to June 2006. Controls were matched to RRS activation patients by admission date and unit. Rapid response system activation patients were then excluded from analysis. Chart reviews identified positive criteria on non-RRS patients. For controls, physiologic data were collected from admission until the day of matched RRS activations. Data were collected in patients with adverse events for the 8 hours preceding events. A total of 262 patients (2.8%) had 271 adverse events including 245 ICU transfers and 26 arrests. Positive criteria were found during 21.1% of control admissions (68/323). Positive criteria preceded 60.8% of the ICU transfers (158/260; 95% confidence interval, 54.8%-66.7%). However, 76.9% of patients with an arrest did not have previous positive criteria (20/26; 95% confidence interval, 60.7%-93.1%). Intensive care unit transfers with positive criteria were more likely to die than patients without criteria (35.4% versus 20.6%; odds ratio [OR], 2.1). Positive criteria most strongly associated with life-threatening adverse events were tachypnea (OR, 31.1) and 100% supplemental oxygen (OR, 13.7). The early warning conditions used to activate RRS teams were only fair predictors of acute deterioration, although early signs of respiratory failure during routine monitoring were strongly associated with future life-threatening adverse events. Improved respiratory monitoring may improve outcomes from RRS interventions.
Overuse of blood products is common, but prior efforts to improve transfusion decisions have met ... more Overuse of blood products is common, but prior efforts to improve transfusion decisions have met with limited success. This study examines transfusion practices before and after a conventional educational intervention followed by a randomized controlled trial of a decision support (DS) intervention with computerized physician order entry (CPOE) for red blood cell, platelet, and fresh-frozen plasma orders. The study was conducted in an academic medical center between April 2003 and June 2004. Orders originating from units not using CPOE with DS (e.g., the emergency department) were excluded. Junior housestaff were randomly assigned into a control group and an intervention group who received DS for transfusion orders. Transfusion orders were initially classified according to guideline rules as DS-agree or DS-disagree. Chart reviews assessed inappropriateness for all DS-disagree orders and a sample of DS-agree orders. The total of inappropriate transfusion orders included chart review confirmed DS-disagree orders and DS-agree orders reclassified as inappropriate. The percentages of inappropriate nonemergent transfusion orders during the baseline phase for the entire staff and randomly assigned junior housestaff were 72.6 percent (2154/2967) and 71.9 percent (1259/1752) and improved after conventional education to 63.8 percent (1699/2663; p < 0.0001) and 63.3 percent (1263/1996; p < 0.0001), respectively. The percentage of inappropriate orders in the DS intervention group continued to improve (59.6%, 804/1350; p < 0.0001). Physicians accepted 14 percent (133/939) of new DS-recommended orders, especially recommendations to increase transfusion doses (73%). Education and computerized DS both decreased the percentage of inappropriate transfusions, although the residual amount of inappropriate transfusions remained high.
Serious medication errors are common in hospitals and often occur during order transcription or a... more Serious medication errors are common in hospitals and often occur during order transcription or administration of medication. To help prevent such errors, technology has been developed to verify medications by incorporating bar-code verification technology within an electronic medication-administration system (bar-code eMAR). We conducted a before-and-after, quasi-experimental study in an academic medical center that was implementing the bar-code eMAR. We assessed rates of errors in order transcription and medication administration on units before and after implementation of the bar-code eMAR. Errors that involved early or late administration of medications were classified as timing errors and all others as nontiming errors. Two clinicians reviewed the errors to determine their potential to harm patients and classified those that could be harmful as potential adverse drug events. We observed 14,041 medication administrations and reviewed 3082 order transcriptions. Observers noted 776 nontiming errors in medication administration on units that did not use the bar-code eMAR (an 11.5% error rate) versus 495 such errors on units that did use it (a 6.8% error rate)--a 41.4% relative reduction in errors (P<0.001). The rate of potential adverse drug events (other than those associated with timing errors) fell from 3.1% without the use of the bar-code eMAR to 1.6% with its use, representing a 50.8% relative reduction (P<0.001). The rate of timing errors in medication administration fell by 27.3% (P<0.001), but the rate of potential adverse drug events associated with timing errors did not change significantly. Transcription errors occurred at a rate of 6.1% on units that did not use the bar-code eMAR but were completely eliminated on units that did use it. Use of the bar-code eMAR substantially reduced the rate of errors in order transcription and in medication administration as well as potential adverse drug events, although it did not eliminate such errors. Our data show that the bar-code eMAR is an important intervention to improve medication safety. (ClinicalTrials.gov number, NCT00243373.)
Although sleep deprivation has been shown to impair neurobehavioral performance, few studies have... more Although sleep deprivation has been shown to impair neurobehavioral performance, few studies have measured its effects on medical errors. We conducted a prospective, randomized study comparing the rates of serious medical errors made by interns while they were working according to a traditional schedule with extended (24 hours or more) work shifts every other shift (an "every third night" call schedule) and while they were working according to an intervention schedule that eliminated extended work shifts and reduced the number of hours worked per week. Incidents were identified by means of a multidisciplinary, four-pronged approach that included direct, continuous observation. Two physicians who were unaware of the interns' schedule assignments independently rated each incident. During a total of 2203 patient-days involving 634 admissions, interns made 35.9 percent more serious medical errors during the traditional schedule than during the intervention schedule (136.0 vs. 100.1 per 1000 patient-days, P<0.001), including 56.6 percent more nonintercepted serious errors (P<0.001). The total rate of serious errors on the critical care units was 22.0 percent higher during the traditional schedule than during the intervention schedule (193.2 vs. 158.4 per 1000 patient-days, P<0.001). Interns made 20.8 percent more serious medication errors during the traditional schedule than during the intervention schedule (99.7 vs. 82.5 per 1000 patient-days, P=0.03). Interns also made 5.6 times as many serious diagnostic errors during the traditional schedule as during the intervention schedule (18.6 vs. 3.3 per 1000 patient-days, P<0.001). Interns made substantially more serious medical errors when they worked frequent shifts of 24 hours or more than when they worked shorter shifts. Eliminating extended work shifts and reducing the number of hours interns work per week can reduce serious medical errors in the intensive care unit.
Adverse drug events (ADEs), particularly those involving intravenous medications (IV-ADEs), are c... more Adverse drug events (ADEs), particularly those involving intravenous medications (IV-ADEs), are common among intensive care unit (ICU) patients and may increase hospitalization costs. Precise cost estimates have not been reported for academic ICUs, and no studies have included nonacademic ICUs. To estimate increases in costs and length of stay after IV-ADEs at an academic and a nonacademic hospital. This study reviewed medical records to identify IV-ADEs, and then, using a nested case-control design with propensity-score matching, assessed differences in costs and length of stay between cases and controls. : A total of 4604 adult ICU patients in 3 ICUs at an academic hospital and 2 ICUs at a nonacademic hospital in 2003 and 2004. Increased cost and length of stay associated with IV-ADEs. : Three hundred ninety-seven IV-ADEs were identified: 79% temporary physical injuries, 0% permanent physical injuries, 20% interventions to sustain life, and 2% in-hospital deaths. In the academic ICUs, patients with IV-ADEs had $6647 greater costs (P < 0.0001) and 4.8-day longer stays (P = 0.0003) compared with controls. In the nonacademic ICUs, IV-ADEs were not associated with greater costs ($188, P = 0.4236) or lengths of stay (-0.3 days, P = 0.8016). Cost and length-of-stay differences between the hospitals were statistically significant (P = 0.0012). However, there were no differences in IV-ADE severity or preventability, and the characteristics of patients experiencing IV-ADEs differed only modestly. IV-ADEs substantially increased hospitalization costs and length of stay in ICUs at an academic hospital but not at a nonacademic hospital, likely because of differences in practices after IV-ADEs occurred.
Harmful medication errors, or preventable adverse drug events (ADEs), are a prominent quality and... more Harmful medication errors, or preventable adverse drug events (ADEs), are a prominent quality and cost issue in healthcare. Injectable medications are important therapeutic agents, but they are associated with a greater potential for serious harm than oral medications. The national burden of preventable ADEs associated with inpatient injectable medications and the associated medical professional liability (MPL) costs have not been previously described in the literature. To quantify the economic burden of preventable ADEs related to inpatient injectable medications in the United States. Medical error data (MedMarx 2009-2011) were utilized to derive the distribution of errors by injectable medication types. Hospital data (Premier 2010-2011) identified the numbers and the types of injections per hospitalization. US payer claims (2009-2010 MarketScan Commercial and Medicare 5% Sample) were used to calculate the incremental cost of ADEs by payer and by diagnosis-related group (DRG). The ...
Intravenous (IV) medications are vital in the management of hospitalized patients. Inpatients fre... more Intravenous (IV) medications are vital in the management of hospitalized patients. Inpatients frequently receive several IV medications concurrently, and these are commonly delivered with infusion pump systems. In particular, critically ill patients receive potent "high-alert" IV drugs, many with narrow safety margins requiring careful nursing titration. However, while intravenous medications have important benefits, errors associated with IV medication administration can result in severe or life-threatening adverse drug events (ADEs). Although errors in prescribing are often intercepted, administration errors do not get caught with most current systems While several safety improvements in IV infusion pump design have reduced mechanical complications, errors with IV drug administration such as incorrect programming persist. Intelligent IV infusion pumps have integrated software to provide point of care decision support (DS). This software includes drug library profiles con...
Research in the last decade has identified medication errors as a more frequent cause of unintend... more Research in the last decade has identified medication errors as a more frequent cause of unintended harm than was previously thought. Inpatient medication errors and error-prone medication usage are detected internally by medication error reporting and externally through hospital licensing and accreditation surveys. A hospital's rate of medication errors is one of several measures of patient safety available to staff. However, prospective patients and other interested parties must rely upon licensing and accreditation scores, along with varying access to outcome data, as their sole measures of patient safety. We have previously reported that much higher rates of medication errors were found when an independent audit was used compared with rates determined by the usual process of self-report. In this study, we summarize these earlier findings and then compare the error detection sensitivity of licensing and accreditation surveys with that of an independent audit. When experienced surveyors fail to detect a highly error prone medication usage system, it raises questions about the validity of survey scores as a measure of safety (i.e., lack of medication errors). Replication of our findings in other hospital settings is needed. We also recommend measures for improving patient safety by reducing error rates and increasing error detection.
Computerized physician order entry (CPOE) is an increasingly used technologic tool for entering c... more Computerized physician order entry (CPOE) is an increasingly used technologic tool for entering clinician orders, especially for medications and laboratory and diagnostic tests. Studies in hospitalized patients, including critically ill patients, have demonstrated that CPOE, especially with decision support, improves several outcomes. These improved outcomes include clinical measures such as reductions in serious medication errors and enhanced antimicrobial management of critically ill patients resulting in reduced length of stay. Additionally, several process outcomes have improved with CPOE such as increased compliance with evidence-based practices, reductions in unnecessary laboratory tests and cost savings in pharmacotherapeutics. Future studies are needed to demonstrate the benefits of more patient specific decision support interventions and the seamless integration of CPOE into a wireless, computerized medication administration system.
Journal of the American Medical Informatics Association : JAMIA, Jan 21, 2015
Failure to follow-up nonurgent, clinically significant test results (CSTRs) is an ambulatory pati... more Failure to follow-up nonurgent, clinically significant test results (CSTRs) is an ambulatory patient safety concern. Tools within electronic health records (EHRs) may facilitate test result acknowledgment, but their utility with regard to nonurgent CSTRs is unclear. We measured use of an acknowledgment tool by 146 primary care physicians (PCPs) at 13 network-affiliated practices that use the same EHR. We then surveyed PCPs to assess use of, satisfaction with, and desired enhancements to the acknowledgment tool. The rate of acknowledgment of non-urgent CSTRs by PCPs was 78%. Of 73 survey respondents, 72 reported taking one or more actions after reviewing a CSTR; fewer (40-75%) reported that using the acknowledgment tool was helpful for a specific purpose. Forty-six (64%) were satisfied with the tool. Both satisfied and nonsatisfied PCPs reported that enhancements linking acknowledgment to routine actions would be useful. EHR vendors should consider enhancements to acknowledgment func...
Joint Commission journal on quality and patient safety / Joint Commission Resources, 2005
Infusion devices can be programmed with individual hospitals' "best practice" rules... more Infusion devices can be programmed with individual hospitals' "best practice" rules for intravenous (i.v.) drug administration, and alerts can be provided if dosages fall outside pre-established limits. High variation levelsare common in medical care but can increase safety risk if the variation is unnecessary. The i.v. best practice data sets of drugs from 100 hospitals using one manufacturer's infusion devices were compared to assess the number of drug names used and thevariation in concentrations, dose units, dose limits, and administration practices. The 100 hospitals showed an average of 64 drugs per data set and an average of 113 different drug/concentration 4 combinations. On average, each hospital had designated 6 profiles or unique patient care areas; there were 4 different names per drug across the hospitals (for example, amiodarone had 45 different names). High levels of variation in concentrations were ubiquitous. Overall, 60% of medications had more th...
Critically ill patients require high-intensity care and may be at especially high risk of iatroge... more Critically ill patients require high-intensity care and may be at especially high risk of iatrogenic injury because they are severely ill. We sought to study the incidence and nature of adverse events and serious errors in the critical care setting. We conducted a prospective 1-year observational study. Incidents were collected with use of a multifaceted approach including direct continuous observation. Two physicians independently assessed incident type, severity, and preventability as well as systems-related and individual performance failures. Academic, tertiary-care urban hospital. Medical intensive care unit and coronary care unit patients. None. The primary outcomes of interest were the incidence and rates of adverse events and serious errors per 1000 patient-days. A total of 391 patients with 420 unit admissions were studied during 1490 patient-days. We found 120 adverse events in 79 patients (20.2%), including 66 (55%) nonpreventable and 54 (45%) preventable adverse events a...
Early warning criteria ("criteri... more Early warning criteria ("criteria"), used to activate rapid response system (RRS) teams, may improve patient outcomes by predicting life-threatening adverse events--urgent intensive care unit (ICU) transfers and cardiac arrests. We conducted a case-control study on medicine patients in an academic medical center from May 2005 to June 2006. Controls were matched to RRS activation patients by admission date and unit. Rapid response system activation patients were then excluded from analysis. Chart reviews identified positive criteria on non-RRS patients. For controls, physiologic data were collected from admission until the day of matched RRS activations. Data were collected in patients with adverse events for the 8 hours preceding events. A total of 262 patients (2.8%) had 271 adverse events including 245 ICU transfers and 26 arrests. Positive criteria were found during 21.1% of control admissions (68/323). Positive criteria preceded 60.8% of the ICU transfers (158/260; 95% confidence interval, 54.8%-66.7%). However, 76.9% of patients with an arrest did not have previous positive criteria (20/26; 95% confidence interval, 60.7%-93.1%). Intensive care unit transfers with positive criteria were more likely to die than patients without criteria (35.4% versus 20.6%; odds ratio [OR], 2.1). Positive criteria most strongly associated with life-threatening adverse events were tachypnea (OR, 31.1) and 100% supplemental oxygen (OR, 13.7). The early warning conditions used to activate RRS teams were only fair predictors of acute deterioration, although early signs of respiratory failure during routine monitoring were strongly associated with future life-threatening adverse events. Improved respiratory monitoring may improve outcomes from RRS interventions.
Overuse of blood products is common, but prior efforts to improve transfusion decisions have met ... more Overuse of blood products is common, but prior efforts to improve transfusion decisions have met with limited success. This study examines transfusion practices before and after a conventional educational intervention followed by a randomized controlled trial of a decision support (DS) intervention with computerized physician order entry (CPOE) for red blood cell, platelet, and fresh-frozen plasma orders. The study was conducted in an academic medical center between April 2003 and June 2004. Orders originating from units not using CPOE with DS (e.g., the emergency department) were excluded. Junior housestaff were randomly assigned into a control group and an intervention group who received DS for transfusion orders. Transfusion orders were initially classified according to guideline rules as DS-agree or DS-disagree. Chart reviews assessed inappropriateness for all DS-disagree orders and a sample of DS-agree orders. The total of inappropriate transfusion orders included chart review confirmed DS-disagree orders and DS-agree orders reclassified as inappropriate. The percentages of inappropriate nonemergent transfusion orders during the baseline phase for the entire staff and randomly assigned junior housestaff were 72.6 percent (2154/2967) and 71.9 percent (1259/1752) and improved after conventional education to 63.8 percent (1699/2663; p < 0.0001) and 63.3 percent (1263/1996; p < 0.0001), respectively. The percentage of inappropriate orders in the DS intervention group continued to improve (59.6%, 804/1350; p < 0.0001). Physicians accepted 14 percent (133/939) of new DS-recommended orders, especially recommendations to increase transfusion doses (73%). Education and computerized DS both decreased the percentage of inappropriate transfusions, although the residual amount of inappropriate transfusions remained high.
Serious medication errors are common in hospitals and often occur during order transcription or a... more Serious medication errors are common in hospitals and often occur during order transcription or administration of medication. To help prevent such errors, technology has been developed to verify medications by incorporating bar-code verification technology within an electronic medication-administration system (bar-code eMAR). We conducted a before-and-after, quasi-experimental study in an academic medical center that was implementing the bar-code eMAR. We assessed rates of errors in order transcription and medication administration on units before and after implementation of the bar-code eMAR. Errors that involved early or late administration of medications were classified as timing errors and all others as nontiming errors. Two clinicians reviewed the errors to determine their potential to harm patients and classified those that could be harmful as potential adverse drug events. We observed 14,041 medication administrations and reviewed 3082 order transcriptions. Observers noted 776 nontiming errors in medication administration on units that did not use the bar-code eMAR (an 11.5% error rate) versus 495 such errors on units that did use it (a 6.8% error rate)--a 41.4% relative reduction in errors (P<0.001). The rate of potential adverse drug events (other than those associated with timing errors) fell from 3.1% without the use of the bar-code eMAR to 1.6% with its use, representing a 50.8% relative reduction (P<0.001). The rate of timing errors in medication administration fell by 27.3% (P<0.001), but the rate of potential adverse drug events associated with timing errors did not change significantly. Transcription errors occurred at a rate of 6.1% on units that did not use the bar-code eMAR but were completely eliminated on units that did use it. Use of the bar-code eMAR substantially reduced the rate of errors in order transcription and in medication administration as well as potential adverse drug events, although it did not eliminate such errors. Our data show that the bar-code eMAR is an important intervention to improve medication safety. (ClinicalTrials.gov number, NCT00243373.)
Although sleep deprivation has been shown to impair neurobehavioral performance, few studies have... more Although sleep deprivation has been shown to impair neurobehavioral performance, few studies have measured its effects on medical errors. We conducted a prospective, randomized study comparing the rates of serious medical errors made by interns while they were working according to a traditional schedule with extended (24 hours or more) work shifts every other shift (an "every third night" call schedule) and while they were working according to an intervention schedule that eliminated extended work shifts and reduced the number of hours worked per week. Incidents were identified by means of a multidisciplinary, four-pronged approach that included direct, continuous observation. Two physicians who were unaware of the interns' schedule assignments independently rated each incident. During a total of 2203 patient-days involving 634 admissions, interns made 35.9 percent more serious medical errors during the traditional schedule than during the intervention schedule (136.0 vs. 100.1 per 1000 patient-days, P<0.001), including 56.6 percent more nonintercepted serious errors (P<0.001). The total rate of serious errors on the critical care units was 22.0 percent higher during the traditional schedule than during the intervention schedule (193.2 vs. 158.4 per 1000 patient-days, P<0.001). Interns made 20.8 percent more serious medication errors during the traditional schedule than during the intervention schedule (99.7 vs. 82.5 per 1000 patient-days, P=0.03). Interns also made 5.6 times as many serious diagnostic errors during the traditional schedule as during the intervention schedule (18.6 vs. 3.3 per 1000 patient-days, P<0.001). Interns made substantially more serious medical errors when they worked frequent shifts of 24 hours or more than when they worked shorter shifts. Eliminating extended work shifts and reducing the number of hours interns work per week can reduce serious medical errors in the intensive care unit.
Adverse drug events (ADEs), particularly those involving intravenous medications (IV-ADEs), are c... more Adverse drug events (ADEs), particularly those involving intravenous medications (IV-ADEs), are common among intensive care unit (ICU) patients and may increase hospitalization costs. Precise cost estimates have not been reported for academic ICUs, and no studies have included nonacademic ICUs. To estimate increases in costs and length of stay after IV-ADEs at an academic and a nonacademic hospital. This study reviewed medical records to identify IV-ADEs, and then, using a nested case-control design with propensity-score matching, assessed differences in costs and length of stay between cases and controls. : A total of 4604 adult ICU patients in 3 ICUs at an academic hospital and 2 ICUs at a nonacademic hospital in 2003 and 2004. Increased cost and length of stay associated with IV-ADEs. : Three hundred ninety-seven IV-ADEs were identified: 79% temporary physical injuries, 0% permanent physical injuries, 20% interventions to sustain life, and 2% in-hospital deaths. In the academic ICUs, patients with IV-ADEs had $6647 greater costs (P < 0.0001) and 4.8-day longer stays (P = 0.0003) compared with controls. In the nonacademic ICUs, IV-ADEs were not associated with greater costs ($188, P = 0.4236) or lengths of stay (-0.3 days, P = 0.8016). Cost and length-of-stay differences between the hospitals were statistically significant (P = 0.0012). However, there were no differences in IV-ADE severity or preventability, and the characteristics of patients experiencing IV-ADEs differed only modestly. IV-ADEs substantially increased hospitalization costs and length of stay in ICUs at an academic hospital but not at a nonacademic hospital, likely because of differences in practices after IV-ADEs occurred.
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Papers by Jeffrey Rothschild