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Clinical errors - their causes and frequency in hospitals
Prof Johanna Westbrook
Prof Enrico Coiera
Funded by: HCF Health & Medical Research Foundation
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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)
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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
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Communication load
High communication loads80% of time in communication
Interrupted on average 15/hour
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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
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Which clinical task is most likely to be interrupted?
• 25% of all interruptions occurred while nurses were preparing or administering medications
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Interruptions add to cognitive load, stress and reduce decision-making performance Errors
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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
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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
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Medication Administration Errors Watch nurses as they prepare & administer IV medications
Record interruptions
Compare observed data with patients’ charts to identify errors
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Drs observation studyFollow Drs for 2hr blocks and record:
Work tasks
Interruptions
Multi-tasking
Ask about What tasks next?
How stressed?
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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
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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