Medical Errors, Emergency Medicine and

Electronic RecordsDr 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 CollaborativeChief of Emergencies, Burns and Shock Trauma Center

SevenHills Hospital and Health City, Mumbai, IndiaFaculty of Emergency Medicine and Global HealthUniversity 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/320/7237/788/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 GalwankarMBBS, DNB, FACEE (INDIA), MD, MPH, Dip. ABEM (USA)

gcsagar@yahoo.com