4 ms·
"Of the almost 3,675 medication administrations in the observed operations, 193 events, involving 153 medication errors and 91 adverse drug events, were recorde
by vpribish 11y ago
"Of the almost 3,675 medication administrations in the observed operations, 193 events, involving 153 medication errors and 91 adverse drug events, were recorded ... Almost 80 percent of those events were determined to have been preventable. One-third of the observed medication errors led to an adverse drug event, and the remainder had the potential to cause an adverse event. Of the adverse drug events that were recorded, 20 percent were not associated with a medication error."
that tangle resolves to:
3,675 observations
122 (3.3%) preventable medication errors
31 (0.8%) un-preventable errors
18 (0.05%) adverse drug events not caused by medication error
3% preventable error rate is shocking - but does include things like documentation problems as well as incorrect dosage
btw, the clickbait headline (which is Harvard's fault, not OPs) is seriously getting in the way of communication since I went in to RTFA primed to find garbage.
- belovedeagle 11y agoHow is the headline clickbait? It's a true finding of the study. I would say that a headline leading with the 3% figure would be much more misleading, since the relevant figure for someone considering whether to receive medical treatment (for example) is the "1 in 2" figure. I don't care if the doctors only mess up 3% of my medication interactions; just one is bad enough.
- vpribish 11y agoI called it clickbaity for 2 reasons : 1) The buzzfeed style (gotta have some digits!) didn't help because any reasonable person would have said "half". 2) While 1:2 is technically true it's also the scariest number they could choose and is useless out of context. the level of fear and outrage goes down upon reading the article. also, it really does matter how many erroneous medication interactions you have - not just operations-with-at-least-one. Most of the errors did not have dire consequences (there were no fatalities in the study). Errors are bad, but it's not all errors are equal.
- dang 11y agoOk, we'll put "half" in the title. Seems pretty mild on the linkbait spectrum, but still, that's a good edit.
- cowsandmilk 11y agoMost people have no clue how much medication they receive during surgery, so saying 5% of medication interactions have errors is almost useless. What most people care about: "I'm having surgery today, what are the odds someone will make a mistake during my surgery?"; the headline answers that question directly.
- famousactress 11y agoDo you have experience in healthcare? 3% isn't shocking to me, in fact a number of studies of IV med administration have error rates narrowly on either side of 50% and serious error rates in the double digits. This report suggests that you're safer in surgery than elsewhere in the hospital :| I spent over a decade working on technology solutions to prevent medication errors in hospitals but the bottom line problems that make it a hard problem to solve are: 1. There is a culture of individual blame and so (certainly most) errors go un-reported at all. Systematic identification and process solution is still not healthy, despite 16 years having passed since IOM did an admirable job shining light on the problem [1] 2. There isn't strong enough motivation to fix. It's easier to not report medication errors than to fix them. You or someone you know has probably been victim of a medication given in error one way or another. You just aren't likely aware of it. Many errors aren't very serious, or result in lengthened hospital stays (which guess what!? the responsible institution probably gets paid for). Even the consequences of serious errors aren't often (maybe even usually) attributed to the source mistake. Like many things, money has driven the status quo (more money in ignoring than acknowledging) and it'll drive the solution. Accountability and solutions to this problem will come in the form of payers [your insurance company] finding ways to measure and not reimburse for consequences of errors. Once that motivation exists in a major way solutions will show up very quickly... it's a non-trivial, but also sub-ridiculously-hard problem to solve, from a process/technical perspective. [Edit: I've been out of this problem space for 6-7 years now (because fuck selling things to hospitals [2]) so would love to hear from anyone who knows whether things have changed significantly and my take is now wrong/dated.] [1] https://iom.nationalacademies.org/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf https://iom.nationalacademies.org/~/media/Files/Report%20Fil... [2] Not that it isn't super profitable - particularly if you spend way more on steak-dinner-sales than making shit that actually solves problems! An ironically terrible/frustrating market for anyone who actually cares about clinicians or patients, though.
- vpribish 11y agoMy background is hedge fund and consumer website management - not healthcare. My ignorance aside* - your points, and solution seem right on. It's surprising that in these lightly-regulated, profit-driven, fields we seem to have set up effective processes for error reduction that are not standard in medicine! In trading operations we made (successful) efforts to avoid individual blame, track mistakes, record lessons learned, and continuously develop the processes and systems -- all motivated by the client's money at the end of the day though it was professional culture that was at work minute-by-minute. * if only...