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Medical Errors, Emergency Medicine and Electronic Records Dr Sagar Galwankar MBBS, DNB, FACEE (INDIA), MD, MPH, Dip. ABEM (USA) Founding Chairman of Academic College of Emergency Experts in India CEO of the INDO-US Emergency and Trauma Collaborative Chief of Emergencies, Burns and Shock Trauma Center SevenHills Hospital and Health City, Mumbai, India Faculty of Emergency Medicine and Global Health University of South Florida, Tampa, Florida , USA
Overview • Review Errors • Address Strategies • Look at Electronic Medium for Elimination • Discuss Possible Solutions • Build Systems: Private Versus Social Medicine • Questions
Famous Quote According to the Institute of Medicine’s 1999 Report, To Err is Human, “medical errors can be defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim”.
Error Arena -I • Errors happen when systems are run by humans • More risk when humans play with technology • Video Games are perfect examples • Systems with Standard Systematic approach is essential • Physicians, Nurses, Pharmacists, Laboratory Personnel and Administration are all involved
Error Arena -II • Physician Errors • Pharmacy Error • Nursing Error • Laboratory Error • Ordering Error • Interpretation Error • Administrative Error
Physician Error • History Reporting • Medication Reviewing • Medication Ordering • Tests Ordering • Allergy Reporter • Procedural Notes • Discharge Notes
Pharmacy Error • Prescription • Transcription • Dispensing • Administration • Monitoring
Nursing Errors • Error with Medications • Error with Test and Procedure • Error with Interpretation • Error with Discharge
Laboratory Error • Error with Conducting Tests • Error with Reporting Results Machines to IT Interphase is better than Machines reporting to Humans and humans feeding the data to IT.
Ordering Error • Error with ordering Tests • Error with ordering Procedures • Error with Documentation • Error with Interpretation of orders
Interpretation Error • At every level • Inapropriate communication • Abbreviations • Incorrect forms • Incorrect terminology • Incorrect doses/ procedures/ order segments
Administration Error • Risk Surveillance lapse • Inapropriate billing • Inapropriate coding • Dispensing incorrect test results and patient records
Solutions to Common Errors -I • Building Pre-set orders initiated at triage • Example: Chest Pain, Abdominal Pain etc • Building Pre-Set History Sheet Based on Standard EM History Acquisition related to Common Complaints namely: Chest Pain, SOB, N/V/D, Back Pain, Headache • Building a Common Order Platform • X-ray-UPT Pre-Requisite, Contrast-Consent- Creatinine Pre-Requisite
Solutions to Common Errors -II • Building a ED Standard Medication Registry with Pre-Set Minimal and Maximal Dosing Order Form • Building a Timer to Coordinate every time a Note /Update is added • Electronic Signature Interphase • Bar Code Interphase • Pre-Set Consent Forms for High Risk Care
Solutions to Common Errors –III • Mandatory Electronic Signatures • Laboratory Order/ Result Alerts to Nurses and Physician with High and Lower Color Coded • Verbal Communication for Life Threatening results with Notifier and Notified Signatures • Consult Alerts to be Built In • Pre-Set Discharge Instructions: Admission, Transfer, Mortuary, OT, AMA • Pre-Set Consent Forms with Signature Pad for E- Sign
Solutions to Common Errors -IV • ABBREVIATION POLICY MANDATORY • RISK REVIEW MANDATORY • SHOW CAUSE NOTICE MANDATORY • COLORS MAKE A DIFFERENCE • PACS INTERPHASE NEEDS TO EB COORDINATED • MULTIPLE CENTER PAST RECORDS NEED TO BE INTERPHASED
Solutions to Common Errors -V • DATA TRANSFER FROM LAB INSTRUMENTS AND READERS TO EMR/EHR • SCAN FACILITY WHEN SYSTEM COLLAPSES • BAR CODED CHIP RECORDS • ADMINISTRATIVE SYSTEM FOR BILLING AND AND FOLLOW UP • RISK AND REVIEW TOOLS HAVE TO BE BUILT FOR PERFORMANCE AND REVENUE TRACKING • ALLERGY AND MEDICATION RECONCILATION MANDATORY
Emergency Recording & Pharmacy • Coded Drugs to patients • Orders, Dispensed Drugs all automatically get transcribed with time and to patient order sheet • Allergy Alerter • Pharmacist Instructor Reminder and Reconciler • Dose Verifier • Evidence Based Interphase with EMR System • In built Drug Interaction Repository Interphase • Bar coded consumables tracker
FUTURE TECHNOLOGY • BLACKBERRY / I-PHONE INTERPHASE • TABLET ORDER FORMS • 4G PLATFORM FOR REVIEW • DYNAMIC RECORDING
Conclusion • Medical Error Rate is Inversely Proportional to Patient Safety • Better Patient Safety reflects better care • Patient Safety is paramount as Patient Life is all that matters • Wherever Technology Interphases Protocols Dominate and Only Standard Operations Operate Successful Systems • EXAMPLE: Air Line and Banking Industry
LETS DO OUR BEST AND CONTINOUSLY IMPROVE !
EVIDENCE • A set of approaches utilized to efficiently integrate suppliers and clients (comprised of stores, retailers, wholesalers, warehouses, and manufacturers) so merchandise is produced and distributed at the right quantities, to the right locations, and at the right time, in order to minimize system wide costs while satisfying service level requests. http://www.stanford.edu/~jlmayer • Institute of Medicine. “To Err is Human: Building a Safer Health System”. November 1999. • “Medication Errors Add Time, Money to Hospital Stays”. Oct 7, 2003. http://www.azcentral.com • “Resources for Reducing Medication Errors and Improving Quality in Hospitals”. http://www.mederrors.com • “Graham, Snowe Legislation Would Reduce Medication Errors”. May 3, 2001. http://www.senate.gov/~graham
EVIDENCE • http://www.siemens.com • Goldberg, Laurence A. “Closed-loop Medicines Management System”. Hospital Pharmacy Europe. Nov/Dec 2003. • http://www.healthmgttech.com/archives/h1102errors.htm • “Graham, Snowe Legislation Would Reduce Medication Errors”. May 3, 2001. http://www.senate.gov/~graham • http://www.mdgmedical.com/ServerRx.html
EVIDENCE • Stacklin, Jeff. “Hospitals to Test Rx System”. NE Ohio CrainTech, 6/02/03. http://neohio.craintech.com • Bates D. “Using information technology to reduce rates of medication errors in hospitals”. • http://bmj.bmjjournals.com/cgi/content/full/320/72 37/788/F1 • http://www.healthmgttech.com. Technology’s impact on reducing medication errors. 11/02.
EVIDENCE • http://www.bridgemedical.com/news_2000_02. shtml • Goldberg, Laurence A. “Closed-loop Medicines Management System”, Hospital Pharmacy Europe. November/December 2003. • Dowling, Alan. “Successful Strategies for HCIS Planning”. Financial Focus, 1987.
THANK YOU Dr Sagar Galwankar MBBS, DNB, FACEE (INDIA), MD, MPH, Dip. ABEM (USA) gcsagar@yahoo.com

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Medical errors, emergency medicine and

  • 1. Medical Errors, Emergency Medicine and Electronic Records Dr Sagar Galwankar MBBS, DNB, FACEE (INDIA), MD, MPH, Dip. ABEM (USA) Founding Chairman of Academic College of Emergency Experts in India CEO of the INDO-US Emergency and Trauma Collaborative Chief of Emergencies, Burns and Shock Trauma Center SevenHills Hospital and Health City, Mumbai, India Faculty of Emergency Medicine and Global Health University of South Florida, Tampa, Florida , USA
  • 2. Overview • Review Errors • Address Strategies • Look at Electronic Medium for Elimination • Discuss Possible Solutions • Build Systems: Private Versus Social Medicine • Questions
  • 3. Famous Quote According to the Institute of Medicine’s 1999 Report, To Err is Human, “medical errors can be defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim”.
  • 4. Error Arena -I • Errors happen when systems are run by humans • More risk when humans play with technology • Video Games are perfect examples • Systems with Standard Systematic approach is essential • Physicians, Nurses, Pharmacists, Laboratory Personnel and Administration are all involved
  • 5. Error Arena -II • Physician Errors • Pharmacy Error • Nursing Error • Laboratory Error • Ordering Error • Interpretation Error • Administrative Error
  • 6. Physician Error • History Reporting • Medication Reviewing • Medication Ordering • Tests Ordering • Allergy Reporter • Procedural Notes • Discharge Notes
  • 7. Pharmacy Error • Prescription • Transcription • Dispensing • Administration • Monitoring
  • 8. Nursing Errors • Error with Medications • Error with Test and Procedure • Error with Interpretation • Error with Discharge
  • 9. Laboratory Error • Error with Conducting Tests • Error with Reporting Results Machines to IT Interphase is better than Machines reporting to Humans and humans feeding the data to IT.
  • 10. Ordering Error • Error with ordering Tests • Error with ordering Procedures • Error with Documentation • Error with Interpretation of orders
  • 11. Interpretation Error • At every level • Inapropriate communication • Abbreviations • Incorrect forms • Incorrect terminology • Incorrect doses/ procedures/ order segments
  • 12. Administration Error • Risk Surveillance lapse • Inapropriate billing • Inapropriate coding • Dispensing incorrect test results and patient records
  • 13. Solutions to Common Errors -I • Building Pre-set orders initiated at triage • Example: Chest Pain, Abdominal Pain etc • Building Pre-Set History Sheet Based on Standard EM History Acquisition related to Common Complaints namely: Chest Pain, SOB, N/V/D, Back Pain, Headache • Building a Common Order Platform • X-ray-UPT Pre-Requisite, Contrast-Consent- Creatinine Pre-Requisite
  • 14. Solutions to Common Errors -II • Building a ED Standard Medication Registry with Pre-Set Minimal and Maximal Dosing Order Form • Building a Timer to Coordinate every time a Note /Update is added • Electronic Signature Interphase • Bar Code Interphase • Pre-Set Consent Forms for High Risk Care
  • 15. Solutions to Common Errors –III • Mandatory Electronic Signatures • Laboratory Order/ Result Alerts to Nurses and Physician with High and Lower Color Coded • Verbal Communication for Life Threatening results with Notifier and Notified Signatures • Consult Alerts to be Built In • Pre-Set Discharge Instructions: Admission, Transfer, Mortuary, OT, AMA • Pre-Set Consent Forms with Signature Pad for E- Sign
  • 16. Solutions to Common Errors -IV • ABBREVIATION POLICY MANDATORY • RISK REVIEW MANDATORY • SHOW CAUSE NOTICE MANDATORY • COLORS MAKE A DIFFERENCE • PACS INTERPHASE NEEDS TO EB COORDINATED • MULTIPLE CENTER PAST RECORDS NEED TO BE INTERPHASED
  • 17. Solutions to Common Errors -V • DATA TRANSFER FROM LAB INSTRUMENTS AND READERS TO EMR/EHR • SCAN FACILITY WHEN SYSTEM COLLAPSES • BAR CODED CHIP RECORDS • ADMINISTRATIVE SYSTEM FOR BILLING AND AND FOLLOW UP • RISK AND REVIEW TOOLS HAVE TO BE BUILT FOR PERFORMANCE AND REVENUE TRACKING • ALLERGY AND MEDICATION RECONCILATION MANDATORY
  • 18. Emergency Recording & Pharmacy • Coded Drugs to patients • Orders, Dispensed Drugs all automatically get transcribed with time and to patient order sheet • Allergy Alerter • Pharmacist Instructor Reminder and Reconciler • Dose Verifier • Evidence Based Interphase with EMR System • In built Drug Interaction Repository Interphase • Bar coded consumables tracker
  • 19. FUTURE TECHNOLOGY • BLACKBERRY / I-PHONE INTERPHASE • TABLET ORDER FORMS • 4G PLATFORM FOR REVIEW • DYNAMIC RECORDING
  • 20. Conclusion • Medical Error Rate is Inversely Proportional to Patient Safety • Better Patient Safety reflects better care • Patient Safety is paramount as Patient Life is all that matters • Wherever Technology Interphases Protocols Dominate and Only Standard Operations Operate Successful Systems • EXAMPLE: Air Line and Banking Industry
  • 21. LETS DO OUR BEST AND CONTINOUSLY IMPROVE !
  • 22. EVIDENCE • A set of approaches utilized to efficiently integrate suppliers and clients (comprised of stores, retailers, wholesalers, warehouses, and manufacturers) so merchandise is produced and distributed at the right quantities, to the right locations, and at the right time, in order to minimize system wide costs while satisfying service level requests. http://www.stanford.edu/~jlmayer • Institute of Medicine. “To Err is Human: Building a Safer Health System”. November 1999. • “Medication Errors Add Time, Money to Hospital Stays”. Oct 7, 2003. http://www.azcentral.com • “Resources for Reducing Medication Errors and Improving Quality in Hospitals”. http://www.mederrors.com • “Graham, Snowe Legislation Would Reduce Medication Errors”. May 3, 2001. http://www.senate.gov/~graham
  • 23. EVIDENCE • http://www.siemens.com • Goldberg, Laurence A. “Closed-loop Medicines Management System”. Hospital Pharmacy Europe. Nov/Dec 2003. • http://www.healthmgttech.com/archives/h1102errors.htm • “Graham, Snowe Legislation Would Reduce Medication Errors”. May 3, 2001. http://www.senate.gov/~graham • http://www.mdgmedical.com/ServerRx.html
  • 24. EVIDENCE • Stacklin, Jeff. “Hospitals to Test Rx System”. NE Ohio CrainTech, 6/02/03. http://neohio.craintech.com • Bates D. “Using information technology to reduce rates of medication errors in hospitals”. • http://bmj.bmjjournals.com/cgi/content/full/320/72 37/788/F1 • http://www.healthmgttech.com. Technology’s impact on reducing medication errors. 11/02.
  • 25. EVIDENCE • http://www.bridgemedical.com/news_2000_02. shtml • Goldberg, Laurence A. “Closed-loop Medicines Management System”, Hospital Pharmacy Europe. November/December 2003. • Dowling, Alan. “Successful Strategies for HCIS Planning”. Financial Focus, 1987.
  • 26. THANK YOU Dr Sagar Galwankar MBBS, DNB, FACEE (INDIA), MD, MPH, Dip. ABEM (USA) gcsagar@yahoo.com