It took a recent and sensational headline about 10 preventable deaths in English Montreal hospitals in 2010-11 to draw attention to a nine-year old law that few non-hospital workers knew existed. Under Quebec's Bill 113, a patient has the right to be informed of any health institutional accident with potential consequences for the patient's health or welfare. For that to materialize, hospital workers are obligated by this law to report all errors, and management has to ensure transparency and implement means to reduce mistakes.
In response to Bill 113, the Jewish General Hospital, commonly regarded as one of our best hospitals, has continued to devise preventive measures, and I'll spend the bulk of this article examining how it's dealing with one of the most common blunders by doctors and nurses.
If we look at the 2010-2011 volume of activity at the Jewish General Hospital:
the most common activity is by far the processing of prescriptions. Not surprisingly, most of the accidents involve medication, 1804, or 29.3 % of all reported accidents/incidents. In other Montreal English hospitals, this type of error accounts for an even greater share of the total.
The medication error rate is miniscule (0.3%), but the volume of patients and prescriptions is so large that the number of accidents affects a great deal of lives. Awareness of the statistics, of course, makes the victims and their families feel even worse. It's similar to what goes on in the aviation industry, and a great deal of energy is invested in prevention to drive the number of mistakes even lower.
Here are some strategies that the hospital has been using:
A surprising number of clinics and hospitals still do not have computerized data bases for prescribed drugs. This creates problems when patients move from hospital to hospital or from one doctor to another, a very common practice, especially when the state picks up the bill, as it does here in Quebec.
It will be interesting to see the impact of this precautionary approach on future accident rates. What's worrisome is the unreasonable crowding of patients that Montreal hospitals are expected to handle on a daily basis. If the volume is not alleviated, the errors may continue to occur with a similar frequency, despite the intelligent guidelines, additional paperwork and new committees.
In response to Bill 113, the Jewish General Hospital, commonly regarded as one of our best hospitals, has continued to devise preventive measures, and I'll spend the bulk of this article examining how it's dealing with one of the most common blunders by doctors and nurses.
If we look at the 2010-2011 volume of activity at the Jewish General Hospital:
| Number of radiology exams |
185 751 |
| Number of prescriptions processed |
622 868 |
| Number of surgeries |
13 139 |
the most common activity is by far the processing of prescriptions. Not surprisingly, most of the accidents involve medication, 1804, or 29.3 % of all reported accidents/incidents. In other Montreal English hospitals, this type of error accounts for an even greater share of the total.
The medication error rate is miniscule (0.3%), but the volume of patients and prescriptions is so large that the number of accidents affects a great deal of lives. Awareness of the statistics, of course, makes the victims and their families feel even worse. It's similar to what goes on in the aviation industry, and a great deal of energy is invested in prevention to drive the number of mistakes even lower.
Here are some strategies that the hospital has been using:
One observation that caught my attention was the following:
- Wherever possible, medication is purchased in the final form in which it is to be administered—in other words, no mixing is required. This minimizes the possibility that the concentration of the drug is incorrect.
- Similarly, a system has been adopted that requires the use of a single concentration of certain medications. This eliminates any doubt about the proper concentration of those drugs.
- Drugs in high concentration have been removed from nursing units in non-critical areas.
- Where appropriate, extra warnings have been place on intravenous medication bags.
- Orders for certain high-risk medications are pre-printed to ensure clarity and accuracy, and the maximum dose limit for the pertinent medications.
- Whenever JGH patients receive intravenous medication, they receive these drugs through "smart pumps". These digital pumps are programmed to check a database to confirm that patients are getting the right dose of the right medication at the proper rate. If a potential problem is detected, the pump emits a warning sound and does not allow the medication to be given. As an added safety feature, the smart pumps’ built-in drug library now contains information about minimum and maximum doses of high-risk medications.
When prescriptions or other notes for medication are written by hand, errors can occur because of unclear handwriting and because abbreviations for certain drugs are used by some people, but not by others.The ISMP (Institute for Safe Medical Practices) lists misleading abbreviations that should be avoided. These include omission of the zero before the decimal point, which could lead to the possibility that someone will overlook the point and administer ten times the prescribed dose. One that shocked me was that some practitioners had developed the habit of abbreviating morphine sulfate as MSO4, which was then interpreted as MgSO4(magnesium sulfate). Latin abbreviations are also discouraged in ISMP guidelines. Based on Q.O.D. , short for quaque otram diem (every other day), some doctors wrote OD, intending to say "every day" or "daily", but it was occasionally being interpreted as oculus dexter, which means "right eye".
A surprising number of clinics and hospitals still do not have computerized data bases for prescribed drugs. This creates problems when patients move from hospital to hospital or from one doctor to another, a very common practice, especially when the state picks up the bill, as it does here in Quebec.
It will be interesting to see the impact of this precautionary approach on future accident rates. What's worrisome is the unreasonable crowding of patients that Montreal hospitals are expected to handle on a daily basis. If the volume is not alleviated, the errors may continue to occur with a similar frequency, despite the intelligent guidelines, additional paperwork and new committees.
In short, the undercurrent of attitudes here seems to be that most of the medical professional is unfamiliar with Copernicus. By that I mean, that they may eventually realize that THEY are not the center of the universe, and perhaps they should consider who else may have to follow their notes and instructions. It reeks of medical arrogance.