Transcript No Slide Title

Clinical errors - their causes
and frequency in hospitals
Prof Johanna Westbrook
Prof Enrico Coiera
Funded by: HCF Health & Medical Research
Foundation
Problem
High rates of medical errors and adverse
events
16% of admissions in Aust experience an
adverse event
51% of these were judged to be preventable
Cost in additional bed-days alone of these
errors is estimated at 5% of the health budget.
(Quality in Australian Health Care Study, Wilson et al.,
1995)
Medication Errors
In Australia 2% inpatients experience
harm or death due to medication errors
Estimated errors in 20% of all drug doses
administered in hospital
IV medications have error rates of 50-90%
Only 1 Australian study – 20% error rate in IVs 2
surgical wards
Communication load
High communication loads
80% of time in communication
Interrupted on average 15/hour
Percentage of time nurses spent in
different work tasks
(N=244 hours of observation)
other, 0.8
w ard related
activities, 2.7
supervision, 3.0
direct care, 21.4
documentation, 7.3
in transit, 7.7
indirect care, 11.2
professional
communication, 19.8
social, 11.3
medication tasks,
14.8
Which clinical task is most likely
to be interrupted?
• 25% of all interruptions occurred while
nurses were preparing or administering
medications
Interruptions add to cognitive load,
stress and reduce decision-making
performance
Errors
Aim
To examine the relationships between
clinicians’ cognitive & communication
loads and two types of errors:
Medication administration errors
Task scheduling errors eg forget tasks,
task completion delayed or incomplete
Hypotheses
Being interrupted while preparing or
administering a drug increases the likelihood
of a medication error
Interruptions & multi-tasking in high stress
clinical environments increase task scheduling
errors (ie tasks are left incomplete, delayed or
forgotten)
Clinical experience may compensate for the
effects of a high communication load
Medication Administration Errors
Watch nurses as they
prepare & administer IV
medications
Record interruptions
Compare observed data
with patients’ charts to
identify errors
Drs observation study
Follow Drs for 2hr
blocks and record:
Work tasks
Interruptions
Multi-tasking
Ask about
What tasks next?
How stressed?
Outcomes
Rates & type of IV medication administration
errors
Determine relationship between interruptions
and medication errors
By error type and nurse experience
Measure association of cognitive and
communication load and task scheduling errors
Eg Average time taken to return to interrupted tasks
Recovery from interruptions by clinician experience
Importance
Baseline data to test any interventions
designed to reduce medication errors
New data about clinicians’ communication
loads and errors, first step in designing
effective interventions to support clinicians’
work.
Establishing links between researchers &
health insurance industry