Learning from Errors as a Means to Improve Healthcare Quality and Patient Safety

The healthcare cost associated with adverse and temporary harm events in hospitals is estimated to be over $ 324 million. Further, reviews of patient charts estimate that about 10% of hospital admissions are linked to an adverse event (Levinson, 2010; Rafer et al., 2015). After a review of the Health and Human Services Department’s 2010 report titled “ Adverse Events in Hospitals: National Incidence among Medicare Beneficiaries ” by the Office of Inspector General, the essay discusses questions posed in relation to the findings of the report. The essay also provides a summary of the report’s recommendations and the role of the principle of learning in enhancing healthcare quality and patient safety. 

Definition of Errors, Adverse Events and Preventable Adverse Events 

The report offers the findings of a comprehensive study on the occurrence and effects of adverse events among the Medicare beneficiaries. The report uses the National Coordinating Council of Medication Errors Reporting and Prevention (NCC MERP) Index to categorize errors that can be classified as adverse events based on the level of harm on patients (Levinson, 2010). The report notes that human errors can be knowledge-based, skill-based, and fatigue-associated or may occur due to inability to fall rules and cope with the complicated demands of the healthcare system (Rafer et al., 2015). Errors can also occur due to technical mistakes. Imperatively, based on the NCC MERP index, the report defines medical errors as any preventable events which have the potential to cause or lead to inappropriate use of medication or harm under the control of healthcare practitioners, consumers, and patients. These events may relate to professional practice, healthcare products, processes and systems that may comprise of prescriptions, communication process, labeling of products, the packaging and the nomenclature. The events may also be associated with the dispensation, compounding of the medicines, administration, monitoring, awareness and utilization (NCC MERP, 2016). 

The report also defines adverse events as occurrences that cause harm to patients in the course of medical care. For instance, infections arising from the use of medical equipment like catheter are adverse and undesirable outcomes that are harmful to patients (Levinson, 2010). In Appendix D, the report says that adverse events are those that meet at least of the following criteria: an event on the National Quality Forum list of Serious Reportable Events; or an event on the Medicare’s list of hospital-acquired conditions (HACs) that demands higher payment; or an event whose outcome is in one of the 4 most severe categories on the patient harm index as classified by the index as F-I which include prolonged stays in hospital, permanent harm, life-sustaining action and/ or death. 

The report notes that preventable events or avoidable adverse events are direct outcomes of failures or heed recognized and evidence-based practices and guideline at both system and individual levels. The report asserts that prevention ability is a regulatory criterion for Medicare policy of non-payments for HACs and CMS is required to select those conditions that can be “reasonably prevented through the use existing evidence-based guidelines. 

Function of the NCC MERP 

The National Coordinating Council for Medication Errors Reporting and Prevention was established in 1995 by the United States Pharmacoperial Convention (NCC MERP). The NCC MERP is an autonomous body that comprises of over twenty-seven national organizations with a mission of maximizing the utilization of safe medications and increasing awareness of medical errors by using open communication, enhanced reporting and promoting medication error prevention approaches (NCC MERP, 2016). The main goals and objectives are highlighted in the mission and vision statements. The organization’s vision is to ensure that no patient is harmed through medication errors. The organization monitors adverse events to enhance patient’s safety and integrity of a patient’s data. Adverse events surveillance is essential because of the purposes that it serves which include identification of events which may have immediate impact on a patient’s safety, and informing stakeholders like regulators, and investigators current and essential information concerning events that occur in clinical trials (Rafer et al., 2015). Monitoring also aims at offering a summary of adverse experiences so as to develop appropriate drug or regimen to profile such situations. 

Determination of Adverse Events 

The report asserts that adverse events are determined through physician reviews where physicians ascertain if an adverse event happened, if the event is on the NQF list of Serious Events or Medicare list of HAC, and the level of harm it has on a patient (Levinson, 2010). Lastly, the physician review determines if the event was preventable, its cost to Medicare and any additional event that led to temporary patient harm. Studies demonstrate that the identification of adverse events with hindsight is a complicated and difficult process that requires extensive clinical knowledge, effective documentation, and impartiality by a researcher (CCRNCI NIH, 2016). A review of medical records is the most definitive approach but it is considered expensive. 

Percentage of Adverse Events 

The report notes that about 13.5% of hospitalized Medicare beneficiaries had adverse event experiences during their stays in healthcare facilities. However, physician reviewers ascertained that about 44% of these adverse events and temporary harm events could be prevented (Levinson, 2010). Events associated with surgical procedures were less likely to be preventable as compared to other types of events like hospital acquired infections. However, the report notes that physicians could not determine the remaining five percent of events due to incomplete documentation of medical records or extreme complications in patients’ conditions or healthcare provider. 

Summary of the Recommendations 

The report makes a raft of critical recommendations for all healthcare stakeholders, especially agencies within the Department of Health and Human Services (HHS) as they share responsibility in addressing the issues. Imperatively, it recommends that the Agency for Healthcare Research and Quality (AHRQ) and the CMS broaden their patient safety efforts so as to comprise of all kinds of adverse events (Levinson, 2010). The broadening includes having a broader definition to apply to various activities like setting research priorities, and establishing requisite guideline on hospital reporting of these events among other areas (AHRQ, 2017). The report also recommends that these agencies should improve their efforts in identifying adverse events to help policymakers and researchers in resource allocation where areas with the greatest need are prioritized and certain goals for improvement are set (Levinson, 2010). The enhanced efforts should also include assessment of the effectiveness of particular strategies, and holding healthcare providers accountable and evaluation of progress made in a bid to reduce incidence rate. The report also recommends that CMS needs to offer more incentives to hospitals to mitigate incidence of adverse events through its oversight and payment functions. 

Learning from Errors as a Means to Improve Healthcare Quality and Patient Safety 

Medication errors allow practitioners to know what they should not do. Learning allows practitioners to be better and improve the quality of care to patients. Healthcare quality is defined as the level at which healthcare services for individuals and populations improve their likelihood of desired good health results that are consistent with existing professional knowledge (Rafter et al., 2015). Most of the errors leading to adverse events and harm occur due to defective processes and system and not necessary healthcare practitioners. Processes and other different factors contribute to the complicated nature of healthcare in the country. Consequently, it is vital for people and healthcare facilities to adopt process enhancement methods to identify potential inefficiencies with the aim of preventing errors and changing systems for improved quality outcomes. 

References  

Agency for Healthcare Research and Quality (2017). Adverse Events, Near Misses, and Errors ; 

retrieved from https://psnet.ahrq.gov/primers/primer/34/adverse-events-near-misses-and-errors 

Center for Cancer Research, National Cancer Institute, NIH. (2016). Adverse Events: 

Documenting, Recording, and Reporting. Retrieved from http://clinicaltrialtools.vc.ons.org/file_depot/0-10000000/0-10000/1338/folder/1119270/Adverse+Events.pdf 

Levinson, D. R. (2010) Adverse Events in Hospitals: National Incidence among Medicare 

Beneficiaries . Retrieved from https://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf 

NCC MERP. (2016). Vision and Mission . Retrieved from 

http://www.nccmerp.org/vision-and-mission 

Rafter, N., Hickey, A., Condell, S., Conroy, R., O’Connor, P., Vaughan, D. & William, D. 

(2015) Adverse events in healthcare: learning from mistakes. QJM: An International Journal of Medicine , vol. 108, No.4, pp.273-277. Retrieved from https://doi.org/10.1093/qjmed/hcu145