Clinical errors - their causes and frequency in hospitals

Prof Johanna Westbrook

Prof Enrico Coiera

Funded by: HCF Health & Medical Research Foundation

ProblemHigh 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 loads80% 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

documentation, 7.3

in transit, 7.7

indirect care, 11.2

social, 11.3

medication tasks, 14.8

professional communication, 19.8

direct care, 21.4

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 errorsTask scheduling errors eg forget tasks, task completion delayed or incomplete

HypothesesBeing 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 studyFollow Drs for 2hr blocks and record:

Work tasks

Interruptions

Multi-tasking

Ask about What tasks next?

How stressed?

OutcomesRates & 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 tasksRecovery 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