Medical Errors and the United States Healthcare System _ ___________________________________________
Review the 24 analysis questions from the Joint Commission Framework for Root Cause Analysis and Corrective Actions to identity potential root causes of errors highlighted in this case. In particular: 1. Were there any steps in the process that did not occur as intended? 2. What human factors were relevant to the outcome? 3. What are the other areas in the healthcare organization where this could happen? This case is adapted from Singh, 2022. CASE STUDY A ten-year-old boy was brought to a clinic by his parents. The child had a running nose for the past ten days. The nurse was out sick at the time of the visit, and the receptionist was assisting the physician. On examination, the physician diagnosed simple allergic rhinitis and advised the parents to use over-the-counter antihistamine cetirizine. The parents were provided with a post visit summary and instructions. After two days, the mother returned to the clinic and reported that the boy was lethargic. The clinic’s front desk said that they would convey the information to the physician, who was very busy that day. The physician later said that it is typical for children taking cetirizine to be slightly sleepy. He had the front deck tell the parents to keep the child home from school for the next few days. The mother decided to take the child to a specialist because she was concerned about the level of sedation. On the second opinion, a review of current medications was performed. It was noted that the child was taking a cetirizine tablet 10 mg two times a day, which is higher than typically recommended. A review of the error was performed at the clinic. It was noted that there was a typographical error in the instructions given to the parents, saying 10 mg twice a day, instead of 5 mg twice a day, which was the dose the physician intended. Review the 24 analysis questions from the Joint Commission Frame- work for Root Cause Analysis and Corrective Actions to identity potential root causes of errors highlighted in this case. In particular: 1. Were there any steps in the process that did not occur as intended? 2. Was staff properly qualified and currently competent for their responsibilities? 3. How did actual staffing compare with ideal level?
MEDICAL ERROR REDUCTION The following Congressional actions and ACA policies were developed with the objective of reducing medical error: • In 2011, the Centers for Medicare and Medicare Services (CMS) launched the Hospital Patient Safety initiative, which piloted new surveyor tools for assessing compliance with federal regulations [53]. • Under the Hospital Inpatient Quality Reporting (HIQR) program, CMS reimburses hospitals that successfully report designated quality measures a higher annual update, while failure to report the measures results in a payment reduction. CMS publicly reports the data on its “Hospital Compare” website. • The Deficit Reduction Act of 2005 required CMS to select at least two hospital-acquired conditions for which hospitals would not be paid higher Medicare reimbursement. Since 2008, CMS has maintained a list of hospital-acquired conditions that includes catheter-associated UTIs, falls and trauma, late-stage pressure ulcers, surgical site infections, and DVT [54]. Under the Patient Protection and Affordable Care Act of 2009, starting in 2011, CMS applied this payment policy to the Medicaid program to encourage hospitals to actively prevent these conditions. • The Patient Safety and Quality Improvement Act of 2005 established Patient Safety Organizations under supervision of the AHRQ. Patient Safety Organizations receives reports of patient safety events from healthcare providers and provides analyses of these events [53]. They operate under federal privacy protections to encourage providers to report medical errors and to work with healthcare systems to resolve systemic issues. • The Patient Safety and Quality Improvement Act of 2005 authorized AHRQ to promulgate “Common Formats” so that hospitals can report adverse events in a uniform, unambiguous manner [54]. The goal of Common Formats is to allow for the “apples to apples” comparison of medical errors across multiple hospital systems.
This case is adapted from Singh, 2022.
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MDFL0627
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