Many nurses have
poor mathematical skills
They do not know where to put the
decimal point
©
Patients might get
10 times more
©
Patients might get
10 times more
or
10 times less
©
Patients might get
10 times more
or
10 times less
medication than they should
©
If you’re lucky!
©
In 1999 between
45,000 and 98,000
Americans died due to medical errors
many due to
the calculation mistake
©
…
…the nurse made
The calculation mistake.'‘
BayCare Health System Florida (2008).
©
©
"It was
the calculation mistake”…
…
…the nurse made
The calculation mistake.''
©
The statistics in the 1999 Institute of
Medicine report were startling. The
report stated that between 45,000 and
98,000 Americans die each year as the
result of medical errors.
http://www.surgeryencyclopedia.com/L
a-Pa/MedicalErrors.html#ixzz0R6k7vjTh
©
We know that it was the human error,''
said the spokeswoman for the hospital,
part of the BayCare Health System.
©
Some 7,000 U.S. hospital patients die
each year and more than 750,000 are
injured as a result of medication
mistakes.
These errors have many causes
©
Medical errors
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Introduction and definitions
The subject of medical errors is not a new one. However, it did not come to widespread attention in the United States until the 1990s, when government-sponsored research about the problem
was undertaken by two physicians, Lucian Leape and David Bates. In 1999, a report compiled by the Committee on Quality of Health Care in America and published by the Institute of Medicine
(IOM) made headlines with its findings. As a result of the IOM report, President Clinton asked the Quality Interagency Coordination Task Force (QuIC) to analyze the problem of medical errors
and patient safety, and make recommendations for improvement. The Report to the President on Medical Errors was published in February 2000.
It is important to understand the terms used by the government and health-care professionals in describing medical errors in order to distinguish between injury or death resulting from mistakes
made by people on the one hand, and unfortunate results of treatment on the other. Some allergic reactions to medications or failures to respond to cancer treatment, for example, result from
physical differences among patients or the known side effects of certain treatments, and not from prescribing the wrong drug or therapy for the patient's condition. This type of negative outcome
is called an adverse event in official documents. Adverse events can be defined as undesirable and unintentional, though not necessarily unexpected, results of medical treatment. An example
of an adverse event is discomfort in an artificial joint that continues after the expected recovery period, or a chronic headache following a spinal tap.
A medical error, on the other hand, is an adverse event that could be prevented given the current state of medical knowledge. The QuIC task force expanded the IOM's working definition of a
medical error to cover as many types of errors as possible. Their definition of a medical error is as follows: "The failure of a planned action to be completed as intended or the use of a wrong
plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems." A useful, brief definition of a medical error is that it is a preventable adverse event.
Statistics
The statistics contained in the IOM report were startling. The authors of the report stated that between 45,000 and 98,000 Americans die each year as the result of medical errors. If the lower
figure is used as an estimate, deaths in hospitals resulting from medical errors are the eighth leading cause of mortality in the United States, surpassing deaths attributable to motor vehicle
accidents (43,458), breast cancer (42,297), and AIDS (16,516). Moreover, these figures refer only to hospitalized patients; they do not include people treated in outpatient clinics, ambulatory
surgery centers , doctors' or dentists' offices, college or military health services, or nursing homes . Medical errors certainly occur outside hospitals; in 1999, the Massachusetts State Board of
Registration in Pharmacy estimated that 2.4 million prescriptions are filled incorrectly each year in that state—which is only one of 50 states.
In terms of health-care costs, the IOM report estimated that medical errors cost the United States about $37.6 billion each year; about half this sum pays for direct health care.
The United States is not unique in having a high rate of medical errors. The United Kingdom, Australia, and Sweden are presently undertaking studies of their respective health care systems.
British experts estimate that 40,000 patients die each year in the United Kingdom as the result of medical errors. Australia has been testing a new system for reporting errors since 1995.
Description
There is no single universally accepted method of classifying medical errors in order to describe them more fully. The 2000 QuIC report lists five different classification schemes that have been
used:
type of health care given (medication, surgery, diagnostic imaging, etc.)
severity of the injury (minor discomfort, serious injury, death, etc.)
legal definitions (negligence, malpractice, etc.)
setting (hospital, emergency room, intensive care unit , nursing home, etc.)
persons involved (physician, nurse, pharmacist, patient, etc.)
The importance of these different ways to classify medical errors is their indication that different types of errors require different approaches to prevention and problem solving. For example,
medication errors are often related to such communication problems as misspelled words or illegible handwriting, whereas surgical errors are often related to unclear or misinterpreted diagnostic
images.
Causes of medical errors
The causes of medical errors are complex and not yet completely understood. Some causes that have been identified include the following:
Communication errors. One widely publicized case from 1994 involved the death of a Boston newspaper columnist from an overdose of chemotherapy for breast cancer due to misinterpretation
of the doctor's prescription; the patient was given four times the correct daily dose, when the doctor intended the dosage to be administered instead over a four-day period. Other cases involve
medication mix-ups due to drugs with very similar names. The Food and Drug Administration (FDA) has identified no fewer than 600 pairs of look-alike or sound-alike drug names since 1992.
The increasing specialization and fragmentation of health care. The more people involved in a patient's treatment, the greater the possibility that important information will be missing along the
chain.
Human errors resulting from overwork and burnout. For some years, hospital interns, residents, and nurses have attributed many of the errors made in patient care to the long hours they are
expected to work, many times with inadequate sleep. With the coming of managed care, many hospitals have cut the size of their nursing staff and require those that remain to work mandatory
overtime shifts. A study published in the Journal of the American Medical Association in October 2002 found a clear correlation between higher-than-average rates of patient mortality and
©
The statistics contained in the Institue of Medicine report were
startling. The authors of the report stated that between 45,000 and
98,000 Americans die each year as the result of medical errors. If the
lower figure is used as an estimate, deaths in hospitals resulting from
medical errors are the eighth leading cause of mortality in the United
States, surpassing deaths attributable to motor vehicle accidents
(43,458), breast cancer (42,297), and AIDS (16,516). Moreover, these
figures refer only to hospitalized patients; they do not include people
treated in outpatient clinics, ambulatory surgery centers , doctors' or
dentists' offices, college or military health services, or nursing homes
. Medical errors certainly occur outside hospitals; in 1999, the
Massachusetts State Board of Registration in Pharmacy estimated
that 2.4 million prescriptions are filled incorrectly each year in that
state—which is only one of 50 states.
Read more: http://www.surgeryencyclopedia.com/La-Pa/MedicalErrors.html#ixzz0R6k7vjTh
©
The subject of medical errors is not a new one. However, it did not
come to widespread attention in the United States until the 1990s,
when government-sponsored research about the problem was
undertaken by two physicians, Lucian Leape and David Bates. In
1999, a report compiled by the Committee on Quality of Health Care in
America and published by the Institute of Medicine (IOM) made
headlines with its findings. As a result of the IOM report, President
Clinton asked the Quality Interagency Coordination Task Force (QuIC)
to analyze the problem of medical errors and patient safety, and make
recommendations for improvement. The Report to the President on
Medical Errors was published in February 2000.
Read more: http://www.surgeryencyclopedia.com/La-Pa/MedicalErrors.html#ixzz0R6kcQHPd
©
Some 7,000 U.S. hospital patients die
each year and more than 750,000 are
injured as a result of medication
mistakes.
These errors have many causes
©
Some 7,000 U.S. hospital patients die each
year and more than 750,000 are injured as a
result of medication mistakes. These errors
have many causes, and many potential
solutions, according to a Rutgers-Camden
nursing scholar who has studied the topic
extensively.
©
"It's a major problem. What we're seeing is
just the tip of the iceberg," says Kathleen
Ashton, a clinical associate professor of
nursing at Rutgers-Camden, who adds that
many more medication errors are never
reported, and some aren't even detected
©
TAMPA - One person's error killed Elisha
Crews Bryant, hospital officials said last
week: a miscalculation by a nurse that
overdosed the pregnant 18-year-old with a
drug meant to slow her labor.
©
But the drug that killed Bryant, magnesium
sulfate, is a known hazard. At least 52
overdoses have occurred in recent years,
including seven cases in which the patient
died or remains in a persistent vegetative
state, according to a widely cited nursing
journal article.
©
We know that it was the human error,''
said Lisa Patterson, spokeswoman for
the hospital, which is part of BayCare
Health System. "It was the calculation
mistake. The nurse made the calculation
mistake.''
©
this article in the Chicago Tribune, September 10, 2000, Tribune Staff Writer
Michael J. Berens, reports on the appalling changes that are putting patient's
lives in jeopardy. The problems in large part are due to our United States federal
government injecting itself into the formerly private and excellent healthcare
systems. The other victims are the nurses themselves as you will see in this
thorough examination of the issue.
Overwhelmed and inadequately trained nurses kill and injure thousands of
patients every year as as hospitals sacrifice safety for an improved bottom line,
a Tribune investigation has found.
Since 1995, at least 1,720 hospital patients have been accidentally killed and
9,584 others injured from the actions or inaction of registered nurses across the
country, who have seen their daily routine radically altered by cuts in staff and
other belt-tightening in U.S. hospitals.
Registered nurses are the primary sentinels of patient care, providing first
warning and rapid intervention for those too sick to help themselves. But the
majority of hospitals in Chicago and nationally are quietly eliminating or
supplanting the role of their best-trained, highest-paid nurses, creating a
harried work environment that often compromises patient welfare.
The Tribune analyzed 3 million state and federal computer records to create a
database that, for the first time, quantifies the hidden role registered nurses
play in medical errors. Because of incomplete reporting in the medical field,
these numbers only hint at the full scope of the problem.
And because of lax disciplinary oversight in most states, including Illinois,
nurses who make errors or have problems such as a drug addiction rarely
receive severe punishment; sometimes they travel to a new state to practice
again.
Lapses in nursing care sometimes have only minor consequences, but many are
©
from a newly graduated nurse who was left alone to perform a delicate medical
procedure without training.
In Denver, Mary Heidenreich, 78, was killed early last year when a nurse, who
reported being overwhelmed with the care of 15 patients, inadvertently
delivered a fatal dose of drugs into an intravenous line.
At a Wichita, Kansas, hospital where staff shortages left up to 20 critically ill
patients in the hands of one nurse, patient Deedra Tolson, 38, bled to death
unnoticed after a hysterectomy and 61-year-old Shirley Keck's pleas for help
went unanswered until she suffered permanent brain damage.
Registered nurses-who receive more education and perform more complicated
procedures than licensed practical nurses or nurse aids-outnumber doctors 2-1
in hospitals.
State and national disciplinary records indicate, and researches agree, that
registered nurses long have been responsible for more patient deaths and
injuries each year than any other health-care professional-largely because they
have more contact with patients. But the errors have intensified in recent years
as working conditions have put more pressure on nurses.
Although most nurses perform their jobs with distinction, they increasingly find
themselves both victims of hospital mismanagement and perpetrators of
medical errors, forced to walk a thin line between do no harm and doing the
impossible.
"Do you know how afraid I was that I was going to fry somebody?" said Marge
Sampson, 55, a registered nurse who worked two decades at the state's largest
public hospital, the University of Illinois at Chicago Medical Center, before stress
drover her to a medical office job.
"It's so scary to spend eight hours, flying by the seat of your pants and just
praying," she said. "In my day, they taught you never4 to give a drug until you
©
Medication Math Errors and the Nursing Student
A shocking number of patients die every year in United States hospitals as the result of
medication errors, and many more are harmed. One widely cited estimate (Institute of
Medicine, 2000) places the toll at 44,000 to 98,000 deaths, making death by medication
"misadventure" greater than all highway accidents, breast cancer, or AIDS. If this estimate is
in the ballpark, then nurses (and patients) beware: Medication errors are the forth to sixth
leading cause of death in America.
How many medication errors are miscalculation errors? No one really knows since by some
estimates as little as one in ten errors are reported (Pepper, 2002). Of reported errors one
FDA study (Thomas, et. al., 2001) found that 7% were due to "miscalculation of dosage or
infusion rate." Combining this estimate with the estimate for total deaths, as many as 3,000
to 6,800 deaths are caused annually by medication math errors. This would mean that in
the average hospital one patient dies every year or two because someone makes a
miscalculation, and one or two patients are sub-lethally harmed each month. As future
nurses, then, there is a distinct possibility that we will harm, or even cause the death of, a
patient over the course of our career.
If we believe the adage "first do no harm" applies to us, then what can we possibly do to
minimize miscalculation errors? If we only aim to pass Medication Math with an 80% or
above, are we setting the bar high enough? It might be late some Saturday night, you're the
only RN on the floor, the hospital pharmacy is closed, and it's up to you to calculate a
needed dosage. Surely getting the right answer only 80% of the time is not acceptable.
©
If we believe the adage "first do no harm" applies to us, then what can we possibly do to
minimize miscalculation errors? If we only aim to pass Medication Math with an 80% or
above, are we setting the bar high enough? It might be late some Saturday night, you're the
only RN on the floor, the hospital pharmacy is closed, and it's up to you to calculate a
needed dosage. Surely getting the right answer only 80% of the time is not acceptable.
Perhaps the problem you need to solve is a little different than any you've seen before or
recall seeing in the textbook. How confident will you be that your calculation is correct?
The time to build confidence is while we are students. I suggest that as conscientious
students we should aim for 95% or better. We should, then, carefully study, learn from, and
thereby avoid repeating what mistakes we do make, so that by the time we are working in
the real world we can be confident that, if we are vigilant enough, we can approach 100%
proficiency. Since "to err is human," we will always be at risk of not achieving a goal of
100% proficiency, but we cannot aim for less, and knowing that we are always at risk will
make us extremely careful.
Neither effort, desire to avoid error, nor carefulness, however, is enough. We need the right
tools and techniques that will help us avoid miscalculations. I believe that dimensional
analysis is the most appropriate tool available to us. It is, by far, the best method of solving
medication math problems with the least chance of making errors. As nurses we're not likely
to ever use whatever algebra, trigonometry, calculus, or statistics we may know and (even
better?) we need make no effort to learn these subjects, but we should strive for a deep
understanding of, and proficiency in, dimensional analysis (DA).
The good news is that mastery of DA is not at all an unobtainable goal. While few could
master a vast subject such as algebra in a lifetime, most students should be able to master
DA in a few weeks of focused effort. Mastery would mean the ability to solve any problem
that could crop up, no matter how it is presented, while avoiding pitfalls, and retaining
©
This study found that doctors expected a higher level of skill in drug calculation from their
peers than they were able to achieve themselves. Furthermore, junior doctors and those
working in non-critical care areas scored lower on a drug-dose calculation test. Both
these groups reported that their previous education in drug calculations was less than
adequate when compared with more senior doctors and those working in critical care
areas.
Doctors’ self-predicted and actual scores were similar, suggesting they have good insight
into their own skill and limitations. However, the mean score judged as adequate was
significantly higher than the mean score the doctors achieved themselves: 80% of
participants expected a colleague to score 90% or more to practise adequately in a
clinical environment. These high expectations, and the group’s failure to achieve them,
raise medicolegal concerns about the criteria doctors use to judge their peers. In a US
study, 83% of 175 respondents believed prescribing errors were unacceptable and
should not occur.15
A UK study found that doctors generally had a poor level of skill in calculating drug
doses.5,8 We found similarly that junior and newly graduated doctors perform most
poorly, and that critical care doctors perform best. Within the critical care specialties, we
surveyed a relatively large number of senior anaesthetists, partly explaining the higher
scores in this group.
Strikingly, participants who stated they had “never” or “unlikely” ever made a mistake in a
drug-dose calculation scored significantly lower (62.7%) in the calculation test than those
who admitted to past errors (90.6%). This result may be accounted for by the more
experienced doctors, who performed better but had longer careers in which to make a
mistake. However, it also raises concern that some doctors may lack insight into their
ability and overestimate their skill, thus being unaware of their current or past mistakes.
©
Reassuringly, most doctors in our study (89%) said they “mostly” or “always” double-check
their own drug-dose calculations. This is a higher proportion than in a US study,15 which
showed that only half of interns always double-checked their calculated doses. It is difficult
to know whether our results truly reflect better workplace practices in Australia, as it has
been shown repeatedly that self-reported compliance with desired behaviour is higher than
objectively measured compliance.15,16 However, doctors who performed worst in the
calculation test were most likely to have a second staff member check their calculated
doses. This reflects awareness of their deficiencies and supports the belief that the selfreporting of workplace habits was accurate.
Our study also supports previous arguments for standardised drug labelling.5,6,17 Nearly
all doctors preferred solutions to be expressed in mg/mL. This preference was supported by
significantly higher scores for calculations involving concentrations expressed as mg/mL.
Concentrations expressed as percentages or ratios resulted in more calculation errors,
potentially leading to adverse events.5,6,18,19
Standardising the units for drug concentrations in solution to mass per unit volume would
lessen the risk of error by reducing the complexity of dose calculation, particularly in timecritical, high-stress areas.8 These strategies for risk reduction have been effective in the
aviation and nuclear industries2,5 and are well suited but underutilised in acute care
medicine.
©
Some may argue that a written test is a poor predictor of the true
performance of doctors in clinical practice. However, residents who show
poor calculation skills in a written examination are likely to perform even
more poorly under stressful conditions.18
It is of concern that over three-quarters of participants (79%) reported
never being tested in the skill of drug-dose calculation during their
careers, suggesting this skill is assumed. One doctor calculated a dose
that was 1000 times the correct dose (Question 7, Box 2). Doctors need to
be trained to identify “alarms” that a dose calculation is incorrect or
dangerous.20 Directly achievable recommendations to reduce errors
include encouraging safe workplace practices such as double-checking
one’s own calculations, cross-checking with another staff member, and
utilising web-based medication programs.
Our study had a number of limitations. The newly constructed
questionnaire was not validated, although it was derived from previously
used and validated surveys. We cannot exclude the possibility of selection
bias, but the response rate was high (74%), from a large representative
sample of the hospital’s medical staff, and few data were missing.
Although some potential participants may have declined to participate if
they expected to perform poorly, this would have biased towards higher
actual scores, which is alarming given the generally poor scores achieved.
Lastly, it was beyond the scope of this study to assess whether incorrect
calculations would have led to clinical errors and affected patient
outcomes.
©
This study showed that the doctors surveyed expected a higher level
of skill in calculating drug doses from their colleagues than they
achieved or expected of themselves. In addition, junior doctors and
those in non-critical care specialties performed more poorly, clearly
confirming the need for improved teaching of drug-dose calculations to
medical students and junior staff.21,22
To address calculation, mathematical process and arithmetic errors,
we recommend ongoing training and enforcement via formal, regular
assessment of skill in calculating drug doses for all
doctors.7,8,15,17,23,24 In this way, the skill levels of individual
doctors may be more likely to reflect the high expectations they have
of their colleagues. Since the completion of this study, we have been
approached by the hospital’s medical education office to run formal
training sessions on this skill for intern staff. This will enable us to
conduct further, more robust, research.2,25
©