Economic measurement of medical errors using a hospital claims database.

OBJECTIVE: The primary objective of this study was to estimate the occurrence and costs of medical errors from the hospital perspective. METHODS: Methods from a recent actuarial study of medical errors were used to identify medical injuries. A visit qualified as an injury visit if at least 1 of 97 injury groupings occurred at that visit, and the percentage of injuries caused by medical error was estimated. Visits with more than four injuries were removed from the population to avoid overestimation of cost. Population estimates were extrapolated from the Premier hospital database to all US acute care hospitals. RESULTS: There were an estimated 161,655 medical errors in 2008 and 170,201 medical errors in 2009. Extrapolated to the entire US population, there were more than 4 million unique injury visits containing more than 1 million unique medical errors each year. This analysis estimated that the total annual cost of measurable medical errors in the United States was $985 million in 2008 and just over $1 billion in 2009. The median cost per error to hospitals was $892 for 2008 and rose to $939 in 2009. Nearly one third of all medical injuries were due to error in each year. CONCLUSIONS: Medical errors directly impact patient outcomes and hospitals' profitability, especially since 2008 when Medicare stopped reimbursing hospitals for care related to certain preventable medical errors. Hospitals must rigorously analyze causes of medical errors and implement comprehensive preventative programs to reduce their occurrence as the financial burden of medical errors shifts to hospitals.

Sensemaking of patient safety risks and hazards.

In order for organizations to become learning organizations, they must make sense of their environment and learn from safety events. Sensemaking, as described by Weick (1995), literally means making sense of events. The ultimate goal of sensemaking is to build the understanding that can inform and direct actions to eliminate risk and hazards that are a threat to patient safety. True sensemaking in patient safety must use both retrospective and prospective approach to learning. Sensemaking is as an essential part of the design process leading to risk informed design. Sensemaking serves as a conceptual framework to bring together well established approaches to assessment of risk and hazards: (1) at the single event level using root cause analysis (RCA), (2) at the processes level using failure modes effects analysis (FMEA) and (3) at the system level using probabilistic risk assessment (PRA). The results of these separate or combined approaches are most effective when end users in conversation-based meetings add their expertise and knowledge to the data produced by the RCA, FMEA, and/or PRA in order to make sense of the risks and hazards. Without ownership engendered by such conversations, the possibility of effective action to eliminate or minimize them is greatly reduced.

The association between duration of storage of transfused red blood cells and morbidity and mortality after reoperative cardiac surgery.

Red blood cells (RBCs) undergo numerous changes during storage; however, the clinical relevance of these storage "lesions" is unclear. We hypothesized that the duration of storage of transfused RBCs is associated with mortality after repeat sternotomy for cardiac surgery, because these patients are at high risk for both RBC transfusion and adverse outcome. We retrospectively analyzed 434 patients who underwent repeat median sternotomy for coronary artery bypass graft or valve surgery and who received allogeneic RBCs. Three-hundred-twenty-one (74%) patients met the criteria for eligibility. After adjusting for the effects of confounders and the total number of RBC transfusions, the duration of storage of the oldest RBC unit transfused was found to be associated with both in-hospital mortality (Cox proportional hazard ratio (HR) = 1.151; P < 0.0001) and out-of-hospital mortality (HR = 1.116; P < 0.0001). The mean duration of storage of transfused RBCs was also an independent predictor of in-hospital mortality (HR = 1.036; P < 0.0001). Independent associations between the duration of storage of transfused RBCs and acute renal dysfunction and intensive care unit and hospital length of stay were also observed. The duration of storage of RBCs is associated with adverse outcome after repeat sternotomy for cardiac surgery. The clinical significance of this finding should be investigated in a large, randomized, blinded clinical trial.

The Medical Event Reporting System for Transfusion Medicine: will it help get the right blood to the right patient?

The Medical Event Reporting System for Transfusion Medicine (MERS-TM) collects, classifies, and analyzes events that potentially could compromise the safety of transfused blood to facilitate system improvement. This system is designed to collect data on near misses as well as actual events. Near-miss events are a valuable source of data because they occur more frequently than, but share many characteristics and causes of, actual events. Further, although most current reporting efforts describe only what has occurred with little attention to what caused the event, MERS-TM includes a standardized method of causal analysis. The standardization provided by MERS allows users to compare their experience with that of other organizations, which speeds learning across the entire transfusion medicine community. Important features of the MERS-TM system are that it is able to capture threats, hazards, near misses, injuries, and deaths; characterizes failures and recoveries systematically; identifies and provides causal codes for the entire range of system defects including technical, organizational, cultural, and human factors; raises staff awareness about error management; is easily integrated with existing quality assurance programs; has a consistent and straightforward classification method; enables compliance with mandatory Food and Drug Administration reporting and accreditation requirements; has features to deal with a high volume of reports; supplies Web-based training, data entry, and analysis; and provides comparative benchmarks from comparable institutions.

Experience with the medical event reporting system for transfusion medicine (MERS-TM) at three hospitals.

BACKGROUND: The MERS-TM assists hospital transfusion services to identify, analyze, and correct system events relating to the delivery of blood to patients. METHODS: The MERS-TM system was used from February of 1999 to December 2002. All reported near-miss and actual events were recorded and analyzed. RESULTS: During these 47 months, 4670 events were reported by the transfusion service. Of these events, 94% were classified as a near-miss event and 93% were detected before the blood product was administered. No ABO-incompatible transfusions were detected despite transfusion of 50,137 units of red blood cells. High severity events with the potential for patient harm accounted for 241 (5%) of the 4670 events. Nursing related events accounted for 188 (78%) of the high severity events. In one out of 4430 (0.023%) samples tested, a high severity sample-testing event was detected. In one out of 1550 (0.06%) samples collected, a high severity sample-collection event was detected. CONCLUSION: An event reporting system is essential if one is to determine where and how often events are occurring within the transfusion process.

Prevalence and cost of hospital medical errors in the general and elderly United States populations.

OBJECTIVE: The primary objective of this study was to quantify the differences in the prevalence rate and costs of hospital medical errors between the general population and an elderly population aged ≥65 years. METHODS: Methods from an actuarial study of medical errors were modified to identify medical errors in the Premier Hospital Database using data from 2009. Visits with more than four medical errors were removed from the population to avoid over-estimation of cost. Prevalence rates were calculated based on the total number of inpatient visits. RESULTS: There were 3,466,596 total inpatient visits in 2009. Of these, 1,230,836 (36%) occurred in people aged ≥ 65. The prevalence rate was 49 medical errors per 1000 inpatient visits in the general cohort and 79 medical errors per 1000 inpatient visits for the elderly cohort. The top 10 medical errors accounted for more than 80% of the total in the general cohort and the 65+ cohort. The most costly medical error for the general population was postoperative infection ($569,287,000). Pressure ulcers were most costly ($347,166,257) in the elderly population. LIMITATIONS: This study was conducted with a hospital administrative database, and assumptions were necessary to identify medical errors in the database. Further, there was no method to identify errors of omission or misdiagnoses within the database. CONCLUSIONS: This study indicates that prevalence of hospital medical errors for the elderly is greater than the general population and the associated cost of medical errors in the elderly population is quite substantial. Hospitals which further focus their attention on medical errors in the elderly population may see a significant reduction in costs due to medical errors as a disproportionate percentage of medical errors occur in this age group.

Errors in transfusion medicine: have we learned our lesson?

The phrase "patient safety" represents freedom from accidental or preventable harm due to events occurring in the healthcare setting. Practitioners aim to reduce, if not prevent, medical errors and adverse outcomes. Yet studies performed from many perspectives show that medical error constitutes a serious worldwide problem. Transfusion medicine, with its interdisciplinary intricacies and the danger of fatal outcomes, serves as an exemplar of lessons learned. Opportunity for error in complex systems is vast, and although errors are traditionally blamed on humans, they are often set up by preexisting factors. Transfusion has inherent hazards such as clinical vulnerabilities (eg, contracting an infectious agent or experiencing a transfusion reaction), but there also exists the possibility of hazards associated with process errors. Sample collection errors, or preanalytic errors, may occur when samples are drawn from donors during blood donation, as well as when drawn from patients prior to transfusion-related testing, and account for approximately one-third of events in transfusion. Errors in the analytic phase of the transfusion chain, slips and errors in the laboratory, comprise close to one-third of patient safety-related transfusion events. As many as 40% of mistransfusions are due to errors in the postanalytic phase: often failures in the final check of the right blood and the right patient at the bedside. Bar-code labels, radiofrequency identification tags, and even palm vein-scanning technology are increasingly being utilized in patient identification. The last phase of transfusion, careful monitoring of the recipient for adverse signs or symptoms, when performed diligently can help prevent or manage a potentially fatal reaction caused by an earlier process error or an unavoidable physiologic condition. Ways in which we can and do deal with potential hazards of transfusion are discussed, including a method of hazard reduction termed inherently safer design. This approach aims to lessen risk, with elimination of a hazard or the reduction of its occurrence as primary. In blood transfusion, elimination and marked reduction of some hazards has been employed to good effect. However, there is still a heavy reliance on procedural methods in the essentially manual steps constituting the phases of the transfusion chain. Some hospitals have created a new role of transfusion safety officer to assist in the effort of monitoring, identifying, and resolving conditions that may lessen safety.