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The role of hospital management in reducing medical errors

Nagara CS

Med J Malaysia, 2003 Mar;58 Suppl A:83-5.
PMID: 14556355
Matched MeSH terms: Medical Errors/prevention & control*
Resilient healthcare in patient safety

Lee YF

Med J Malaysia, 2017 04;72(2):89-90.
PMID: 28473669

No abstract available.

Matched MeSH terms: Medical Errors/prevention & control
Critical incident monitoring in anaesthesia (2)

Choy CY

Curr Opin Anaesthesiol, 2008 Apr;21(2):183-6.
PMID: 18443485 DOI: 10.1097/ACO.0b013e3282f33592

PURPOSE OF REVIEW: Updates on developments in critical incident monitoring in anaesthesia, and assesses its role in improving patient safety.
RECENT FINDINGS: Critical incident reporting has become more widely accepted as an effective way to improve anaesthetic safety, and has continued to highlight the importance of human errors and system failures. The establishment of an international database also improves critical incident reporting. Experiences from the national reporting and learning system in the UK have provided some solutions to the many problems and criticisms faced by the critical incident reporting technique. Direct observations to detect errors are more accurate than voluntary reporting of critical incidents, and may be a promising new approach.
SUMMARY: Critical incident monitoring is a valuable tool in ensuring patient safety due to its low cost and the ability to provide a comprehensive body of detailed qualitative information. The qualitative information gathered can be used to develop strategies to prevent and manage existing problems, as well as to plan further initiatives for patient safety. Novel approaches should complement existing methods to achieve better results. The development of a culture which emphasises safety should go hand in hand with current audit activities.

Matched MeSH terms: Medical Errors/prevention & control*
Medico-legal risk, clinical negligence and the practice of travel medicine

Kennedy KM, Flaherty GT

J Travel Med, 2016 May;23(5).
PMID: 27432905 DOI: 10.1093/jtm/taw048
Matched MeSH terms: Medical Errors/prevention & control*
Fulltext Critical incident monitoring in anaesthesia (1)

Choy YC

Med J Malaysia, 2006 Dec;61(5):577-85.
PMID: 17623959

Critical incident monitoring in anaesthesia is an important tool for quality improvement and maintenance of high safety standards in anaesthetic services. It is now widely accepted as a useful quality improvement technique for reducing morbidity and mortality in anaesthesia and has become part of the many quality assurance programmes of many general hospitals under the Ministry of Health. Despite wide-spread reservations about its value, critical incident monitoring is a classical qualitative research technique which is particularly useful where problems are complex, contextual and influenced by the interaction of physical, psychological and social factors. Thus, it is well suited to be used in probing the complex factors behind human error and system failure. Human error has significant contributions to morbidities and mortalities in anaesthesia. Understanding the relationships between, errors, incidents and accidents is important for prevention and risk management to reduce harm to patients. Cardiac arrests in the operating theatre (OT) and prolonged stay in recovery, constituted the bulk of reported incidents. Cardiac arrests in OT resulted in significant mortality and involved mostly de-compensated patients and those with unstable cardiovascular functions, presenting for emergency operations. Prolonged-stay in the recovery extended period of observation for ill patients. Prolonged stay in recovery was justifiable in some cases, as these patients needed a longer period of post-operative observation until they were stable enough to return to the ward. The advantages of the relatively low cost, and the ability to provide a comprehensive body of detailed qualitative information, which can be used to develop strategies to prevent and manage existing problems and to plan further initiatives for patient safety makes critical incident monitoring a valuable tool in ensuring patient safety. The contribution of critical incident reporting to the issue of patient safety is far from clear and very difficult to study. Efforts to do so have tended to rely on incident reporting, the only practical approach when funding is limited. The heterogeneity of critically ill patients as a group means that huge study populations would be required if other research techniques were to be used. In the era of evidence-based medicine, anaesthetists are looking for alternative evidence-based solutions to problems that we have accepted traditionally when we cannot quantify for good practical reasons. In the quest for patient safety, investment should be made in reliable audit, detection and reporting systems. The growing recognition that human error usually result from a failure of a system rather than an individual should be fostered to allow more lessons to be learnt, an approach that has been successful in other, safety-critical industries. New technology has a great deal to offer and investment is warranted in novel fail-safe drug administration systems. Last but not the least the importance of simple and sensible changes and better education should be remembered.

Matched MeSH terms: Medical Errors/prevention & control*
Reducing medical errors in primary care using a pPragmatic complex intervention

Khoo EM, Sararaks S, Lee WK, Liew SM, Cheong AT, Abdul Samad A, et al.

Asia Pac J Public Health, 2015 Sep;27(6):670-7.
PMID: 25563351 DOI: 10.1177/1010539514564007

This study aimed to develop an intervention to reduce medical errors and to determine if the intervention can reduce medical errors in public funded primary care clinics. A controlled interventional trial was conducted in 12 conveniently selected primary care clinics. Random samples of outpatient medical records were selected and reviewed by family physicians for documentation, diagnostic, and management errors at baseline and 3 months post intervention. The intervention package comprised educational training, structured process change, review methods, and patient education. A significant reduction was found in overall documentation error rates between intervention (Pre 98.3% [CI 97.1-99.6]; Post 76.1% [CI 68.1-84.1]) and control groups (Pre 97.4% [CI 95.1-99.8]; Post 89.5% [85.3-93.6]). Within the intervention group, overall management errors reduced from 54.0% (CI 49.9-58.0) to 36.6% (CI 30.2-43.1) and medication error from 43.2% (CI 39.2-47.1) to 25.2% (CI 19.9-30.5). This low-cost intervention was useful to reduce medical errors in resource-constrained settings.

Matched MeSH terms: Medical Errors/prevention & control*
The impacts of second generation e-prescribing usability on community pharmacists outcomes

Peikari HR, Shah MH, Zakaria MS, Yasin NM, Elhissi A

Res Social Adm Pharm, 2015 May-Jun;11(3):339-51.
PMID: 25262599 DOI: 10.1016/j.sapharm.2014.08.011

The results from past studies about the effects of second-generation e-prescribing systems on community pharmacists' outcomes and practices are inconclusive, and the claims of effectiveness and efficiency of such systems have not been supported in all studies. There is a strong need to study the factors that lead to positive outcomes for the users of these systems.

Matched MeSH terms: Medical Errors/prevention & control
Implementation of an event reporting system in a transfusion medicine unit: a local experience

Usin MF, Ramesh P, Lopez CG

Malays J Pathol, 2004 Jun;26(1):43-8.
PMID: 16190106

Event reporting can provide data to study the failure points of an organization's work process. As part of the ongoing efforts to improve transfusion safety, a Medical Event Reporting System Transfusion Medicine, (MERS - TM) as designed by Kaplan et al was implemented in the Transfusion Medicine Unit of the University Malaya Medical Centre to provide a standardized means of organized data collection and analysis of transfusion errors, adverse events and near misses. An event reporting form was designed to detect, identify, classify and study the frequency and pattern of events occurring in the unit. Events detected were classified according to Eihdhoven Classification model (ECM) adopted for MERS - TM. Since our system reported all events, we called it Event Reporting System - Transfusion Medicine (ERS-TM). Data was collected and analyzed from the reporting forms for a period of five months from January 15th to June 15th 2002. The initial half of the period was a process of evaluation during which 118 events were reported, coded, analyzed and corrective measures adopted to prevent the recurrence of the same event. The latter half saw the reporting of 122 events following the adoption of corrective measures. There was a reduction in the occurrence of some events and an increase in others, which were mainly beyond the organization's control. A longer period of evaluation is necessary to identify the underlying contributory causes that can be useful to develop plans for corrective and preventive action and thereby reduce the rate of recurrence of errors through proper training and adoption of just culture.

Matched MeSH terms: Medical Errors/prevention & control
Investigating health information systems-induced errors

Yusof M, Sahroni MN

Int J Health Care Qual Assur, 2018 Oct 08;31(8):1014-1029.
PMID: 30415623 DOI: 10.1108/IJHCQA-07-2017-0125

PURPOSE: The purpose of this paper is to present a review of health information system (HIS)-induced errors and its management. This paper concludes that the occurrence of errors is inevitable but it can be minimised with preventive measures. The review of classifications can be used to evaluate medical errors related to HISs using a socio-technical approach. The evaluation could provide an understanding of errors as a learning process in managing medical errors.
DESIGN/METHODOLOGY/APPROACH: A literature review was performed on issues, sources, management and approaches to HISs-induced errors. A critical review of selected models was performed in order to identify medical error dimensions and elements based on human, process, technology and organisation factors.
FINDINGS: Various error classifications have resulted in the difficulty to understand the overall error incidents. Most classifications are based on clinical processes and settings. Medical errors are attributed to human, process, technology and organisation factors that influenced and need to be aligned with each other. Although most medical errors are caused by humans, they also originate from other latent factors such as poor system design and training. Existing evaluation models emphasise different aspects of medical errors and could be combined into a comprehensive evaluation model.
RESEARCH LIMITATIONS/IMPLICATIONS: Overview of the issues and discourses in HIS-induced errors could divulge its complexity and enable its causal analysis.
PRACTICAL IMPLICATIONS: This paper helps in understanding various types of HIS-induced errors and promising prevention and management approaches that call for further studies and improvement leading to good practices that help prevent medical errors.
ORIGINALITY/VALUE: Classification of HIS-induced errors and its management, which incorporates a socio-technical and multi-disciplinary approach, could guide researchers and practitioners to conduct a holistic and systematic evaluation.

Matched MeSH terms: Medical Errors/prevention & control