Taking aim at the top 3 patient safety errors in ob/gyn

January 1, 2007
Paul G. Stumpf, MD
Paul G. Stumpf, MD

DR. STUMPF is Vice Chair, Director of Education, and Director of Reproductive Endocrinology Division, Department of Obstetrics and Gynecology, Newark Beth Israel Medical Center, Newark, N.J.

What can you do right now in your daily practice to prevent the three most common-and potentially dangerous-types of medical errors?

Although the patient safety movement is now well over a decade old, we have yet to see a major impact across the United States.1,2 One reason could be the challenge of putting abstract principles to practical use at local hospitals and individual physician offices.3 Despite a few model programs being created and some successes at a handful of large institutions, their approaches may not work for health-care providers with more limited resources.

For example, most of us now know that medication errors are the most common and most dangerous of the errors that occur in daily practice. Even so, many institutions and physician practices still haven't instituted safety practices like electronic prescribing.

Our goal is to point out steps you can take right now to better address the top three most common types of serious medical errors: medication errors, surgical errors, and tracking errors (Table 1).

DRUG ERRORS

[Medication errors are of four types: prescribing (physician ordering) errors, transcription and verification errors, pharmacy dispensing and delivery errors, and administration (nurse-to-patient) errors.] When medication errors lead to patient injuries, they're often called adverse drug events (ADEs)-which affect an estimated 6% of hospitalized patients. Moreover, ADEs are to blame for about 20% of all disabling patient injuries due to medical errors. Errors in order writing most often cause the almost 60% of ADEs considered preventable.1

What can you do? For starters, [write clearly. Avoid abbreviations that can be misinterpreted (Table 2). Be sure to distinguish between "sound-alike drugs." Use electronic systems for generating and transmitting prescriptions, such as computerized physician order entry, which can reduce drug errors in certain settings.3 Physicians can also design and support protocols, including standardized drug concentrations,] for some "high-risk" drugs, such as anticoagulants, electrolyte solutions, and perhaps oxytocin.

Since almost half of all drug errors are linked to the prescriber having insufficient information about the patient or drug-or both-help to implement clinical decision support programs in your institutions and practices.5 These support systems can provide the prescriber with critical contemporaneous data, including a patient's characteristics such as drug allergies, up-to-date physiologic data (i.e., urine output, blood pressure), her most recent lab results (i.e., creatinine, electrolyte levels), and detailed information about a drug's contraindications and dosage adjustments. Access to this information can help avoid prescribing errors.

[All prescriptions should include detailed instructions for administering the drug to help prevent errors when patients receive them.] Pharmacy dispensing errors reportedly occur in almost 2% of prescriptions filled (that's more than 50 million errors during the filling of three billion prescriptions annually in the US), 6.5% of which were judged clinically important.6 Give patients as much information as possible at the time you prescribe a drug; that may help them spot a mistake when it's dispensed or administered.

SURGICAL ERRORS

Harvard researchers showed that nearly half of all adverse events (AEs) among hospitalized patients were associated with a surgical procedure, with 14% of AEs caused by wound infections and 13% attributed to technical complications.7 Postoperative complications account for up to 22% of preventable patient deaths.8 More than 70 million in-patient and out-patient surgeries are performed each year in the US. There were 300 cases of surgical errors involving the wrong part or side of the body, the wrong procedure, or the wrong patient between 1995 and 2004, according to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Of these, 59% involved surgeons operating on the wrong side of a patient, 19% involved the wrong body site, 10% the wrong surgical procedure, and 12% the wrong patient.8 JCAHO says these factors can raise the risk of wrong-site surgery: too many surgeons involved in the case, too many procedures during a single surgical visit, unusual time pressures to start or complete the procedure, and a patient's unusual physical characteristics (morbid obesity, physical deformity).10

New pre-op rules. JCAHO has now instituted rules, called the "Universal Protocol," that require surgeons to [pre-operatively verify all relevant documents and studies and to sign the patient's incision site before the operation begins with a marker that won't wash off] in the operating room.11 Then immediately before starting the operation, the whole surgical team must stop all other work ("time out") to confirm the patient's identity and the intended surgical site (with the patient cooperating, if possible) and to document that the whole surgical team (nurses, anesthetists, and technicians, too) is on the same page about precisely what procedure will be done and on what body part. This universal protocol is endorsed by a host of organizations, including the American College of Obstetricians and Gynecologists.12

Prophylactic antibiotics. ACOG, JCAHO, the National Quality Forum (NQF), and the Center for Medicare and Medicaid Services (CMS) all endorse appropriate and timely use of prophylactic antibiotics to prevent surgical infections.13 [Strict criteria define an effective prophylactic antibiotic. It must be of low toxicity, have an established safety record in patients, not be routinely used for treating serious infections, include in its spectrum of activity the microorganisms most likely to cause infection, reach a useful concentration in relevant tissues during the procedure, and be given for a short time in a way that will ensure it's still present in surgical sites at the time of the incision.14,15]

In 2006, the Surgical Care Improvement Program (SCIP) endorsed process measures to help prevent cardiac, respiratory, postoperative venous thromboembolic complications, and postop surgical wound infections. The project's stated aim is to cut surgical complications in the US by 25% by 2010.16

TRACKING ERRORS: a plan for follow-up

Any busy practice handles a slew of orders for and results from imaging and laboratory tests, consultations to other professionals, and referrals for procedures, all of which require follow-up. Your professional responsibility generally includes confirming a patient's compliance with testing or treatment instructions, interpreting test results and treatment outcomes, and communicating to her the results, interpretation, and plan. Clearly, within this complex process, the chances for errors of omission abound.

If a serious diagnosis is missed or delayed, damaging consequences can ensue. The fact that a patient has a responsibility to go for that test or treatment you've recommended won't necessarily get you off the hook from pursuing adequate follow-up. [Don't rely on the "no news is good news" approach, which implies that if a woman doesn't hear from you, she can assume test results were normal.17] Such a policy could bury a misplaced test result forever.

Often overlooked is the need to track phone calls and after-hours care, such as follow-up of emergency room visits, especially for results of tests ordered outside the usual office routine and those that arrive long after a patient encounter. [Adequate, timely communication with covering physicians to identify issues needing follow-up is essential to an effective tracking and reminder system.]

Tracking systems must also remind patients to obtain routine screening tests. One study that used a regular mail reminder system showed a 40% increase in getting patients to go in for a Pap smear (although there was no impact on getting mammograms).18 Identifying all the barriers to patients' compliance with testing needs further study. Meanwhile, you can encourage women to do so by emphasizing the reason for and importance of the test and telling them how to schedule and obtain it.

A culture of patient safety

It's been suggested that changes in the system of delivering patient care bring the most benefit in terms of safety,19 so what can you do to advance the culture of patient safety in your local institutions? You can increase awareness by discussing the safety aspects of care at every opportunity: on rounds, at department meetings, in discussions with administrators, and in teaching residents and medical students. You can monitor medical errors and "near misses" in your department and institution.20 You can help create or support protocols and guidelines at your institution to reduce the chance of error. You can improve communication among all members of your health-care team so that opportunities for errors are reduced.

Tools and resources you can use right now

Sources of practical information about implementing patient safety techniques include:

  • ACOG (http://www.acog.org), which has general tools and information and ones specific to women's health care, like pertinent Committee Opinions and the Voluntary Review of Quality of Care program, aimed at institutions' ob/gyn departments.
  • The Joint Commission International Center for Patient Safety (http://www.jcipatientsafety.org), which offers tools and practical guidelines for institutions and individual physicians.
  • The National Patient Safety Foundation (http://www.npsf.org), which maintains a ListServ of about 3,500 people (which gives valuable concrete recommendations for specific patient safety issues), and the largest bibliography in the world on patient safety.
  • The National Center for Patient Safety (NCPS) of the Veterans Health Administration (http://www.patientsafety.gov), which has materials for patients and professionals. All of the above sites provide links to other patient safety Web sites, as well.

The time is ripe to add more patient safety techniques to our daily practice. Let's target the top three areas of medical errors, namely, medication, surgical, and tracking errors. Many organizations can provide tools, information, and practical steps to help us improve patient safety at the local level.

DR. STUMPF is Vice Chair, Director of Education, and Director of Reproductive Endocrinology Division, Department of Obstetrics and Gynecology, Newark Beth Israel Medical Center, Newark, N.J. Although he is also Chair, ACOG Committee on Patient Safety and Quality Improvement, the views expressed in this article are those of the author and are not represented as the official policy or position of the American College of Obstetricians and Gynecologists.

REFERENCES

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5. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995;274:35-43.

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10. American College of Obstetricians and Gynecologists. ACOG Committee Opinion #328: patient safety in the surgical environment. Obstet Gynecol. 2006;107(2 Pt 1):429-433.

11. Joint Commission on Accreditation of Healthcare Organizations. Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. 2003. available at: http://www.jointcommission.org/NR/rdonlyres/E3C600EB-043B-4E86-B04E-CA4A89AD5433/0/universal_protocol.pdf (accessed April 7, 2006).

12. American College of Obstetricians and Gynecologists News Release. ACOG Endorses JCAHO's Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. ACOG Office of Communications December 2, 2003.

13. Birkmeyer JD. Elements of Contemporary Practice, 2 Performance Measures in Surgical Practice, in ACS Surgery Online, Dale DC, Federman DD, eds. Web MD Inc., New York, 2000 (accessed April 7, 2006 http://www.acssurgery.com).

14. American College of Obstetricians and Gynecologists Practice Bulletin #23, Antibiotic prophylaxis for gynecologic procedures.Washington, D.C. January 2001.

15. Classen DC, Evans RS, Pestotnik SL, et al. The timing of prophylactic administration of antibiotics and the risk of surgical wound infection. N Engl J Med. 1992;326:281-286.

16. American Hospital Association Quality Advisory. Surgical Care Improvement Project (SCIP) 2006 (accessed April 7, 2006). http://www.aha.org/aha/key_issues/patient_safety/contents/050923SCIP.pdf).

17. American College of Obstetricians and Gynecologists. Committee Opinion #329. Tracking and reminder systems. Obstet Gynecol. 2006;107:745-747.

18. Burack RC, Gimotty PA, Simon M, et al. The effect of adding Pap smear information to a mammography reminder system in an HMO: results of randomized controlled trial. Prev Med. 2003;36:547-554.

19. Pearlman MD. Patient safety in obstetrics and gynecology: an agenda for the future. Obstet Gynecol. 2006;108:1266-1271.

20. Forster AJ, Fung I, Caughey S, et al. Adverse events detected by clinical surveillance on an obstetric service. Obstet Gynecol. 2006;108:1073-1083.