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Medical Errors: A Public Health Perspective Learner Course Guide Slide 39 (Singh, Giardina, Meyer, Forjuoh, Reis, & Thomas, 2013) Potential Severity of Injury Associated With Delayed or Missed Diagnoses Severity Rating % of Diagnoses 1=No harm 1.6% 2=Inconvenience 0.0% 3=Very minor harm or little/no remediation 1.0% 4=Minor harm or remediation of treatment 10.0% 5=Considerable harm or remediation of treatment 37.9% 6=Very serious harm/danger/permanent damage 15.8% 7=Serious permanent damage 19.0% 8=Immediate or inevitable death 14.2% The chart presented is illustration of the potential severity of injury associated with the delayed or missed diagnosis. In 86.8% of cases, the potential for injury was classified as moderate to severe. When errors in the diagnostic process were subjected to more in depth research, a modal severity rating of 5 across all 5 processes was determined. Slide 40 CASE STUDY ‒ An 8-year-old girl’s urine sample is mislabeled and reported by the laboratory to contain sperm ‒ The medical examiner’s office determines that all cellular material in the urine has only male DNA and could not come from a female subject ‒ Repeat urine test shows a urinary tract infection Please take a moment to read this case study. It represents a multitude of medical errors which presented great potential for injury: The specimen was labeled with the wrong patient identifiers. The situation has the potential to harm two patients—the patient whose urine was mislabeled as well as the patient who was incorrectly linked to that specimen. Both patients may have ended up with incorrect diagnoses, missed treatment, or treatment which was not indicated. In addition to offering inaccurate diagnostic information, a mis-labeled urine could result in false evidence of infidelity or child abuse. For example, a sexually transmitted parasite, Trichomonas vaginalis, can be identified in urine and can raise suspicions of marital infidelity in adults or child abuse if the specimen was mistakenly labeled for a minor child. 30 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 41 DIAGNOSTIC ERROR PREVENTION ‒ Improved communication ‒ Point of care testing ‒ Follow up on lab tests ‒ Document Presented are four methods for the prevention of diagnostic errors. Communication breakdown between providers and patients contributes to 80% of all errors. Follow-up and tracking of diagnostic data accounts for 14.7% of diagnostic error; and performance and interpretation of diagnostic tests accounts for 13.7% of diagnostic error (Singh et al., 2013). The use of point-of-care testing utilizes hand-held medical devices which are computerized to perform many diagnostics by people who may have little or limited experience and training. The devices used are often not covered by the regulations that govern tests performed in a laboratory setting and the personnel performing point-of-care tests are seldom required to undergo training. Although point-of-care tests have a small risk for erroneous results, the manufacturer’s instructions should be followed carefully to avoid risk of error. Errors in point-of-care testing such as glucose and prothrombin time can have serious consequences because medication dosages are frequently determined by test results. (Wolcott et al., 2008) Failing to inform a patient of an abnormal outpatient diagnostic test result can be a serious error. Finally, if it isn’t documented, it didn’t happen. 31 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 42 TREATMENT ERRORS ‒ Research indicates doctors misdiagnose more than 150,000 patients each year in the primary care setting. ‒ Misdiagnosis commonly results in medical error related to over-treatment and unnecessary treatment. Minue et al., 2014 Misdiagnosis is considered a treatment error which affects more than 150,000 patients annually in the primary care setting. Slide 43 Treatment Errors ‒ Performance of an operation, procedure of test ‒ Administering the treatment ‒ Dosage or method of using a drug ‒ Delay in treatment ‒ Inappropriate care Examples of common treatment errors are: • Error in the performance of an operation, procedure or test; • Error in administering the treatment; • Error in the dose or method of using a drug; • Avoidable delay in treatment or in responding to an abnormal test • Inappropriate care. Slide 44 CASE STUDY ‒ A 38-year-old man has a benign anal cyst surgically removed. ‒ The excised tissue is then microscopically analyzed and found to be cancerous. ‒ New clerk files it before the nurse or the physician reviews it. ‒ The patient is not notified of the test results. ‒ Returns to the hospital four times because of continued pain and discomfort. ‒ Diagnosed as having a sexually transmitted disease. Take a moment to read this case study: A 38-year-old man has an anal cyst (diagnosed as benign) surgically removed. The excised tissue is then microscopically analyzed and found to be cancerous. The primary care facility receives the pathology report and a new clerk files it before the nurse or the physician reviews it. The patient is not notified of the test results. In the interim, he has to return to the hospital four times because of continued pain and discomfort, but, because his records do not indicate that he has cancer and no one rechecks the pathology results, he is diagnosed as having a sexually transmitted disease. 32 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 45 CASE STUDY ‒ The cancer, which has been left untreated, continues to spread, and the man dies a year later. Meanwhile, the cancer, which has been left untreated, continues to spread, and the man dies a year later. The case study provided represents a cascade of medical errors: diagnostic and treatment. When doctors fail to perform adequate tests or fail to properly diagnose illnesses, patients can suffer severe injury or wrongful death as a result. Slide 46 Treatment Errors Medications Errors may occur at any step in the process or at multiple steps in the process Medication administration is a complex process. There is potential for errors to occur at any step in that process - from prescribing the medication to the provision of the drug to the patient. Common causes of medication errors include: • Incorrect diagnosis, • Prescribing errors, • Dose miscalculations, • Poor drug distribution practices, • Drug device related problems, • Incorrect drug administration, • Failed communication, or • Lack of patient education. 33 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 47 Treatment Errors Incorrectly prescribed medication — Due to failure to utilize systems for safely prescribing and ordering medication Treatment errors are commonly associated with incorrectly prescribed medication. There are a number of things which may contribute to an incorrect prescription: Illegible handwritten prescriptions, Insufficient or missing information about co-prescribed medications, Past dose-response relationships, Lab values and allergic sensitivities, Incorrect drug or dose is selected or the regimen is too complex, Telephone orders with failure to read back may result in prescription for sound-alike medication, Drugs with similar-looking names may be incorrectly dispensed when prescriptions are handwritten, or Failure to transmit prescription to the pharmacy. Slide 48 EXAMPLE The illustration provided is an example of a hand-written prescription for Meta date ER 10 mg tablets. Meta date is a drug used in the treatment of Attention Deficit Hyperactivity Disorder (ADHD). Due to the similarity in name, poor penmanship and the omission of the modifier "ER", the pharmacist filled the prescription incorrectly and dispensed methadone 10 mg tablets. Methadone is a morphine-based product used as a heroin substitution therapy and analgesic. Methadone is not used for the treatment of ADHD. 34 It's a New Day in Public Health FDOH Medical Errors: A Public Health