Topic: Quality Improvement vs Medication Error
Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement.
Medical error is arguably the third leading cause of death in the US, and while many arguments can be made that the underlying research is imperfect, it is clear that medical error is still one of the leading causes of untimely death. One of the primary causes of the high death rate is medication errors.
Medication errors result in missed opportunities, injury, and death. When the incorrect dose, incorrect medication, or wrong patient are in play, harm often results. Harm can also occur when incompatible combinations of drugs are administered – either because one drug reduced the efficacy of another, or because they worked similarly and resulted in an effective overdose.
In an attempt to reduce drug-related harm, vendors and providers have tried many different fixes – ranging from making the fonts more readable, to electronic drug-drug interaction checks, to dispensing robots. The results have ranged from inconclusive to significant, but as yet no approach or combination of approaches has yet removed medication errors from the list of top causes of medical error resulting in harm.
Some supporting reading for the chat comes from Physician’s Weekly:
- Medical errors officially the third leading cause of death in U.S.
- System errors, human errors, and common sense
- Perioperative Drug Errors & ADEs
- Reducing Cardiovascular Medication Errors
- Overestimating the effect of medical errors can be detrimental
We will take a QI approach, and discuss the topic using each of the typical arms of the basic Quality Improvement Ishikawa diagram to guide and support discussion. An Ishikawa diagram will be provided ahead of time and during the chat.
Participants will bring their own experiences, perspectives, and expectations to the discussion, but the topics might break down something along these lines:
- Policies: office, organization, or national policies, including MU, HIPAA, etc
- Workflow: how things are done including new patient onboarding, care provision, care coordination, ordering/prescribing, billing, patient transfer, etc.
- Insurance Models, payer systems
- Vendor policies and processes
- Home visits
- Machines (equipment, EHR)
- Medical or office equipment
- Home equipment specific to the patient condition
- Integration/interoperation with other office or medical systems, or user personal health records
- Medication dispensing systems
- Staffing: sufficient and qualified staff
- Training: base training, ongoing training, CME, and patient or carer training
- Attitudes: staff attitudes to technology, adoption vs resistance
- Fatigue (especially alert fatigue)
- Patients: as the “raw material” of the medical process. Patients may come with a range of attitudes, health problems, life situations, and ability to comply with treatment that are challenging and stressful.
- Supplies: medical or office, inferior fax paper,
- Data: ability to securely share with correct patient, specialist, lab, etc
- Patient self-care materials including checklists and how-to instructions, contact information for questions, and self-care consumables
- Drug information sheets
- KPIs: operational metrics required by practice, local government, state, federal
- Quality and safety metrics
- Targets: set by practice, insurer, etc.
- Monitoring of home-care
- Adverse Effects reporting
- Noise: distracting noises, sound levels too high, etc. due to computer systems
- Space: Cramped, uncomfortable work space etc.
- Time: Too little time per patient or order, too little time in a day, too many demands
- Location: things where they should be on the screen, click distance, and location of workstation relative to point of care and patient
Some of the authors of the works cited above may be responding to the following topics, and participants are invited to describe their experiences of medication errors, and offer their insights and observations.
- What Methods increase or reduce the risk of medication errors
- What Machine factors increase or reduce the risk of medication errors
- What People issues increase or reduce the risk of medication errors
- What Materials increase or reduce the risk of medication errors
- What Measurement factors increase or reduce the risk of medication errors
- What Environmental factors increase or reduce the risk of medication errors
MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.
To quote the IHI on what the Triple Aim encompasses:
The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:
- Improving the patient experience of care (including quality and satisfaction);
- Improving the health of populations; and
- Reducing the per capita cost of health care.
The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered.
The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.