Lucy Kester

Prevalence and Causes of Medication Errors: A Review

Following the 1999 Institute of Medicine (IOM) report titled “To Err Is Human,” much attention has been focused on medical errors. In that report, it was estimated that medical errors cost as many as 98,000 lives each year in the United States. The IOM report has spurred scientific study on the causes, consequences, and preventive strategies regarding medical errors. The current paper reviews available literature regarding these issues. MethodsA literature search was conducted using Ovid Technologies/Medline from January 1966 to March 2002. The following search terms were used:medication errors, missed medications, omitted medications, missed dose, and missed treatment. ResultsRates of different types of errors vary across series. For example, the rate with which the wrong drug was administered varies from 0% to 9%. The rate at which drugs were administered with the incorrect frequency ranged from 4% to 25%. Finally, the rate with which drugs were inadvertently omitted ranged from 1.1% to 58%. Reasons commonly cited for missing medications were patients’ unavailability, intolerance of the medication, and the clinicians’ perception that the medication was not needed. ConclusionsGreater attention to reducing medication errors is needed. Proposed strategies include implementing unit dose pharmacy systems and physician order entry systems, enhancing interdisciplinary communication, educating patients regarding their medications, and increased attention to system failures.

Respiratory care protocols in postanesthesia care

Respiratory care protocols have been developed for specific therapies that include the following: oxygen titration, weaning from mechanical ventilation, sampling arterial blood gases, managing bronchospasm and secretions, treating atelectasis, endotracheal extubation, and managing the postextubation airway. Although relatively little attention has been given to using protocols in postanesthesia care, this environment lends itself to applying protocols. In this context, studies have examined and support the use of protocols for titrating supplemental oxygen, weaning patients from mechanical ventilation, and sampling arterial blood gases. As with other previously mentioned respiratory protocols, these protocols have shown efficacy for improving allocation of respiratory care services, cost savings, and favorable clinical outcomes. On this basis, while recognizing the need for further studies, respiratory care protocols implemented by respiratory therapists can be beneficial in the postanesthesia care setting.

A Computer-Aided Audit System for Respiratory Therapy Consult Evaluations: Description of a Method and Early Results

BACKGROUND: Use of respiratory therapist (RT)-guided protocols enhances allocation of respiratory care. In the context that optimal protocol use requires a system for auditing respiratory care plans to assure adherence to protocols and expertise of the RTs generating the care plan, a live audit system has been in longstanding use in our Respiratory Therapy Consult Service. Growth in the number of RT positions and the need to audit more frequently has prompted development of a new, computer-aided audit system. METHODS: The number and results of audits using the old and new systems were compared (for the periods May 30, 2009 through May 30, 2011 and January 1, 2012 through May 30, 2012, respectively). In contrast to the original, live system requiring a patient visit by the auditor, the new system involves completion of a respiratory therapy care plan using patient information in the electronic medical record, both by the RT generating the care plan and the auditor. Completing audits in the new system also uses an electronic respiratory therapy management system. RESULTS: The degrees of concordance between the audited RTs care plans and the “gold standard” care plans using the old and new audit systems were similar. Use of the new system was associated with an almost doubling of the rate of audits (ie, 11 per month vs 6.1 per month). CONCLUSIONS: The new, computer-aided audit system increased capacity to audit more RTs performing RT-guided consults while preserving accuracy as an audit tool. Ensuring that RTs adhere to the audit process remains the challenge for the new system, and is the rate-limiting step.