Higher error in certain groups?

Ross Koppel rkoppel at SAS.UPENN.EDU
Wed Oct 1 04:04:58 UTC 2014


Robert Bell asks about finding errors:

      About 6 years ago, I published an article that attempted to 
measure medication prescribing errors.  We could not get the data we 
thought existed -- a listing of all orders stopped by pharmacists -- so 
we studied all orders stopped by the physicians who ordered them.  After 
some research, we found that 66% (a real percent) of all ordered D/Ced 
within 45 minutes were bad orders. This became the Rapid D/C measure 
that many have used in subsequent research.  JAMIA, Koppel et al, 2008  
(See below for full citation and abstract)

Here is part of the intro to that article -- where we discuss methods of 
finding medication prescribing orders:

1. Medical record analysis catches errors that may not reach
the patient and misses errors linked to undocumented
diagnoses and due to improper or delayed diagnoses.13,14 It
is also time-consuming and expensive.
2. Many manifestations of medication errors go unrecognized
because symptoms are often complex, patients
have multiple systems problems, and polypharmacy may
obscure causes and symptoms.
3. Self-reports of prescribing errors are rare because they are
seldom known (if physicians realize they are making
prescribing errors, they correct them). Self-reports also
are limited by concerns of litigation and status loss.13,15
4. Errors intercepted by colleagues are often corrected informally
and are infrequently reported.13,16,17
5. Observational methods require knowledgeable personnel,
are more time- and money-consuming than chart
analysis, and are far more likely to capture medication
administration and dispensing errors rather than misdiagnoses,
missing information, and poor prescribing.18,19
6. Even pharmacy-intercepted errors are generally handled
with deference and only occasionally logged.6,10,11,15
7. Sentinel or trigger signals (e.g., certain abnormal lab
results, leukopenia, and use of certain drugs) used to
detect or prevent adverse drug events (ADEs) show great
promise for both patient safety and cost effectiveness.
Unfortunately, they quickly generate alert fatigue. Also,
few have been implemented and those that have are
implemented in non-standardized ways and therefore
difficult to compare.20--23
8. Use of combined methods would produce a more comprehensive
analysis, thus mitigating the deficiencies of
each approach. Such an undertaking, however, would be
resource intensive and would neither eliminate undercounts
nor avoid systematic biases.


Now, this method --and these methods-- is/are only for medication 
prescribing errors....which the data indicate are the largest source of 
errors.  But even these _miss __most _of the errors.

Ross

**  More info on the article
*Identifying and Quantifying Medication Errors: Evaluation of**
**Rapidly Discontinued Medication Orders Submitted to a**
**Computerized Physician Order Entry System*
ROSS KOPPEL, PHD, CHARLES E. LEONARD, PHARMD, A. RUSSELL LOCALIO, JD, PHD,
ABIGAIL COHEN, PHD, RUTHANN AUTEN, BA, BRIAN L. STROM, MD, MPH
*A b s t r a c t* All methods of identifying medication prescribing 
errors are fraught with inaccuracies and
systematic bias. A systematic, efficient, and inexpensive way of 
measuring and quantifying prescribing errors
would be a useful step for reducing them.
We ask if rapid discontinuations of prescription-orders--where 
physicians stop their orders within 2 hours--would
be an expedient proxy for prescribing errors?
To study this we analyzed CPOE-system medication orders entered and then 
discontinued within 2 hours. We
investigated these phenomena in real time via interviews with 
corresponding ordering physicians. Each order was
also independently reviewed by a clinical pharmacist or physicians. We 
found that of 114 rapidly discontinued
orders by 75 physicians, two-thirds (35 of 53, PPV  66; 95% CI  
53--77) of medication orders discontinued
within 45 minutes were deemed inappropriate (overdose, underdose, etc.). 
Overall, 55% (63 of 114; 95% CI  46--
64%) of medication orders discontinued within 2 hours were deemed 
inappropriate.
This measure offers a rapid, constant, inexpensive, and objective method 
to identify medication orders with a high
probability of error. It may also serve as a screening and teaching 
mechanism for physicians-in-training.

 J Am Med Inform Assoc. 2008;15:461-- 465. DOI 10.1197/jamia.M2549.



Ross Koppel, Ph.D. FACMI
Sociology Dept and Sch. of Medicine
Senior Fellow, LDI, Wharton
University of Pennsylvania, Phila, PA 19104-6299
215 576 8221 C: 215 518 0134

On 9/30/2014 5:20 PM, Robert Bell wrote:
> Following up on Ross' comments, coud I ask members of the list, what 
> are the top three things each would like to see happen to 
> significantly reduce the deaths and injury that occur with medical 
> errors (including diagnostic). I have the idea that having a priority 
> ranked shopping list of the agreed upon things to start doing would 
> advance the discussion from where it currently rests.
>
> Most seem to agree that we are not making much progress. How can we 
> change this?
>
> Robert Bell, M.D.
>
>
>
>
> ------------------------------------------------------------------------
> *From: * Ross Koppel <rkoppel at SAS.UPENN.EDU>;
> *To: * <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>;
> *Subject: * Re: [IMPROVEDX] Higher error in certain groups?
> *Sent: * Tue, Sep 30, 2014 1:03:15 AM
>
> Rob,     You are making two points....and I'm not sure either 
> disagrees with anything I said.
>
> 1. We need the numbers.  All agree.  I would add that:
>
>     We are probably missing 98% of medication errors.
>     We have excellent data on wrong site surgery and wrong patient surgery
>     We have terrible data on wrong patient errors involving 
> meds....for prescribing, dispensing and administration
>     We have bad data on Dx errors.... but at least one can get a sort 
> of handle on them if one follows the trajectory of the patient over a 
> long time.
> But, yes, we need the numbers and they are hard to get.
>
> 2. Your observations of errors you notice with any of your contacts 
> with the medical profession:  I argue that the errors you observe -- 
> while apparently quite high -- are much lower than what the average 
> patient undergoes.  On the most trivial level, you are literate and 
> you speak English.  On a higher level, they know you're a doc and 
> don't want to screw up.  Most patients, even if we gave them a digital 
> recorder, would be unable to identify the vast majority of errors to 
> which they are subjected.
>
> Heck, I wrote one of the major papers on workarounds to barcode 
> medication admin.   Last month I was in the hospital ED for a bad dog 
> attack.  They gave me the wrist band of a Mr. Thomas Keller, born 
> 1977  (may have been 1971.... I can't remember).
>
> If you are saying you see many errors all the time:  Then yes, 
> absolutely.  If you are saying Docs face more errors than the avg 
> patient, then I disagree.
>
> NOTE:  Many, Many errors are caught and stopped before they harm 
> patients.  And much of the harm that does get through is low level.
>
> Ross
>
> Ross Koppel, Ph.D. FACMI
> Sociology Dept and Sch. of Medicine
> Senior Fellow, LDI, Wharton
> University of Pennsylvania, Phila, PA 19104-6299
> 215 576 8221 C: 215 518 0134
> On 9/29/2014 8:10 PM, Robert Bell wrote:
>> Ross, that has not been my general experience over 40 years. But I 
>> have no way of proving it.
>>
>> There is hardly a contact that I have with the medical profession 
>> that is not associated with some big or small problem, be it the 
>> wrong doctor's name on a urine specimen, lack of communication in a 
>> doctor's office (telling the staff you are there in the waiting room) 
>> being given someone else's paperwork for labwork, having crossed 
>> leads on an EKG read by the physician as normal, surgery that has 
>> unexpected negative results, or missed serious diagnoses, etc. And 
>> yes, many good things have happened.
>>
>> Prior to a talk I gave to staff at a local hospital, I collected my 
>> own errors in every day life that I made. My definition of an error 
>> was something that truly annoyed me. Like leaving my car keys in the 
>> house when jumping into the car in the garage, or doing four shopping 
>> tasks but forgetting the fifth. I seem to remember that on one day I 
>> had 8, and the next day 6 such events.
>>
>> Keeping a list of errors, both small and large, that happen with each 
>> personal medical contact might be valuable!
>>
>> That is why the 440,000 figure for annual deaths, for me, could well 
>> be correct.
>>
>> But in all of this Ross, we need good figures, not guesses.
>>
>> How do we get that information? Can we move very far forward without it?
>>
>> Rob Bell, M.D.
>>
>> Sent from my iPad
>>
>> On Sep 29, 2014, at 5:40 AM, Ross Koppel <rkoppel at SAS.UPENN.EDU 
>> <javascript:return>> wrote:
>>
>>> My guess is that health care professionals get better and safer care 
>>> than most patients, /in general/.  The perceived "higher rates" of 
>>> errors are a reflection of health care professionals ability to 
>>> notice errors that occur to many patients.
>>>
>>>
>>> Ross Koppel, Ph.D. FACMI
>>> Sociology Dept and Sch. of Medicine
>>> Senior Fellow, LDI, Wharton
>>> University of Pennsylvania, Phila, PA 19104-6299
>>> 215 576 8221 C: 215 518 0134
>>> On 9/28/2014 6:07 PM, Hoffer, Edward P.,M.D. wrote:
>>>> Anecdotes abound - doctors and nurses caring for health care professionals, particularly those they know and/or who work at their institution, often cut corners or avoid unpleasant procedures. While this is intended as kindness, it often means appropriate care is withheld.
>>>>
>>>> Whether anecdotes truly reflect reality, I have no way of knowing.
>>>>
>>>> Ed
>>>>
>>>> Edward P Hoffer MD, FACP
>>>>
>>>> ________________________________________
>>>> From: Teresa Graedon [terry.graedon at GMAIL.COM  <javascript:return>]
>>>> Sent: Sunday, September 28, 2014 9:30 AM
>>>> To:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG  <javascript:return>
>>>> Subject: Re: [IMPROVEDX] Higher error in certain groups?
>>>>
>>>> Robert,
>>>>
>>>> That is an interesting idea. How would it work?
>>>>
>>>> I suspect that HCPs are simply more likely to detect errors than less (health-care-) educated patients. I'd be interested in data, though, or a plan to gather the evidence.
>>>>
>>>> Terry Graedon, PhD
>>>> The People's Pharmacy
>>>>
>>>> On Sep 26, 2014, at 10:46 PM, Robert Bell<rmsbell at ESEDONA.NET  <javascript:return>> wrote:
>>>>
>>>>> I have the idea that HCPs, particularly physicians, are more like to be exposed to errors in medicine when they are patients.
>>>>>
>>>>> Is there any truth to this and, also are there other groups of patients that are more likely to be involved in errors when patients?
>>>>>
>>>>> Rob Bell, M.D.
>>>>>
>>>>> Sent from my iPad
>>>>> To unsubscribe from the IMPROVEDX:
>>>>> mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>>>>> or click the following link:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG  <javascript:return>
>>>>>
>>>>> Address messages to:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG  <javascript:return>
>>>>>
>>>>>
>>>>> http://LIST.IMPROVEDIAGNOSIS.ORG/  (with your password)
>>>>>
>>>>>
>>>>> Moderator: Lorri ZippererLorri at ZPM1.com  <javascript:return>, Communication co-chair, Society for Improving Diagnosis in Medicine
>>>>>
>>>>> To unsubscribe from the IMPROVEDX list, click the following link:<br>
>>>>> <a href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1" target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a>
>>>>> </p>
>>>> To unsubscribe from the IMPROVEDX:
>>>> mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>>>> or click the following link:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG  <javascript:return>
>>>>
>>>> Address messages to:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG  <javascript:return>
>>>>
>>>>
>>>> http://LIST.IMPROVEDIAGNOSIS.ORG/  (with your password)
>>>>
>>>>
>>>> Moderator: Lorri ZippererLorri at ZPM1.com  <javascript:return>, Communication co-chair, Society for Improving Diagnosis in Medicine
>>>>
>>>> To unsubscribe from the IMPROVEDX list, click the following link:<br>
>>>> <a href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1" target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a>
>>>> </p>
>>>>
>>>>
>>>> The information in this e-mail is intended only for the person to whom it is
>>>> addressed. If you believe this e-mail was sent to you in error and the e-mail
>>>> contains patient information, please contact the Partners Compliance HelpLine at
>>>> http://www.partners.org/complianceline  . If the e-mail was sent to you in error
>>>> but does not contain patient information, please contact the sender and properly
>>>> dispose of the e-mail.
>>>>
>>>> To unsubscribe from the IMPROVEDX:
>>>> mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>>>> or click the following link:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG  <javascript:return>
>>>>
>>>> Address messages to:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG  <javascript:return>
>>>>
>>>>
>>>> http://LIST.IMPROVEDIAGNOSIS.ORG/  (with your password)
>>>>
>>>>
>>>> Moderator: Lorri ZippererLorri at ZPM1.com  <javascript:return>, Communication co-chair, Society for Improving Diagnosis in Medicine
>>>>
>>>> To unsubscribe from the IMPROVEDX list, click the following link:<br>
>>>> <a href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1" target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a>
>>>> </p>
>>>>
>>>
>>>
>>> ------------------------------------------------------------------------
>>>
>>> Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG 
>>> <javascript:return>
>>>
>>> To unsubscribe from IMPROVEDX: click the following link:
>>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1 
>>> or send email to: 
>>> IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG <javascript:return>
>>>
>>> Visit the searchable archives or adjust your subscription at: 
>>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
>>> Moderator: Lorri Zipperer Lorri at ZPM1.com <javascript:return>, 
>>> Communication co-chair, Society for Improving Diagnosis in Medicine
>>>
>>> To learn more about SIDM visit:
>>> http://www.improvediagnosis.org/
>>
>> ------------------------------------------------------------------------
>>
>>
>> To unsubscribe from IMPROVEDX: click the following link:
>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1 
>> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>>
>> Visit the searchable archives or adjust your subscription at: 
>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
>> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, 
>> Society for Improving Diagnosis in Medicine
>>
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/ 
>
>
> ------------------------------------------------------------------------
>
>
> To unsubscribe from IMPROVEDX: click the following link:
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1 
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>
> Visit the searchable archives or adjust your subscription at: 
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, 
> Society for Improving Diagnosis in Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/ 








To unsubscribe from the IMPROVEDX list, click the following link:<br>
<a href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1" target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a>
</p>

HTML Version:
URL: <../attachments/20141001/1d6bcc07/attachment.html>


More information about the Test mailing list