Montefiore in the News
Why Hospitals Still Make Serious Medical Errors—and How They Are Trying to Reduce Them
- March 12, 2023
By Laura Landro - March 12, 2023 10:00 am ET
Some medical mistakes have been stubbornly hard to eliminate. Now, hospitals hope technology can make a difference.
Hospitals are using technology in a new effort to target medical errors.ILLUSTRATION: JON KRAUSE
Hospitals are turning to technology to address one of the most intractable risks their patients face: medical errors.
More than two decades after the launch of a national patient-safety movement to tackle the alarming toll of medical mistakes, preventing those errors has proved much harder than expected. Despite research that shows some improvement over time, hospitalized patients are still at substantial risk of medication mishaps, hospital infections, breakdowns in nursing care, and complications from surgery and other procedures.
The most persistent problems, which add billions to healthcare costs, were apparent even before the Covid pandemic threw hospitals into chaos, reversing or erasing prior safety gains. According to a study of 2018 data from 11 Harvard Medical School-affiliated Massachusetts hospitals, so-called adverse events—which cause serious harm, prolong hospital stays and contribute to death—affected nearly one in four patients admitted to hospital. Approximately a quarter of those adverse events were preventable with well-known checklists and other safety measures.
“Harm is still distressingly frequent in hospitals, but with wider adoption of robust interventions, many of which use new technology, we can make hospitals safer for patients,” says lead study author David Westfall Bates, medical director of clinical and quality analysis for Mass General Brigham, a hospital system in Boston affiliated with Harvard Medical School.
Now hospitals are harnessing their electronic medical records in new ways to do what previous interventions have failed to do. Of course, success requires buy-in from clinicians who are already overwhelmed and can resist perceived interference with their own judgment. But because the systems are often being designed and tested by fellow doctors and nurses, such innovations may have a greater chance of acceptance.
Here are some of the biggest problems that caregivers are trying to address with technology.
Preventing medication mishaps
Medications are the most common preventable sources of patient injury; in addition to the risk of getting the wrong drug or the wrong dose, medications that patients need can have unanticipated effects.
Hospitals have traditionally relied on voluntary reporting of adverse events by staff, including medication errors, which research shows captures less than 10% of overall safety events. But nurses and doctors must document some actions they take, such as ordering a new medication to treat or reverse a previous mishap. That leaves a trail of information in electronic medical records that are now in use.
One such scenario is patients who become over sedated if they are on medications to sedate them and treat pain and anxiety. Nurses will then treat oversedation, which can be life-threatening, by administering the drug naloxone to reverse drug overdoses. Naloxone must be ordered from the pharmacy through the medical-record system—so even if nurses don’t report the event, there will be a record in the system that points toward possible oversedation.
Hospitals are now scanning electronic medical records with artificial-intelligence algorithms to look for such clues, or triggers, so they can review each case and detect any patterns or system failures that lead to repeat errors that are avoidable, such as not monitoring sedated patients closely enough. They can also notify clinicians of potential harm in real time by, for example, catching changes in lab results that show a medication may be causing harm to the kidney.
Cook Children’s Medical Center turned to patient-safety-risk software from Pascal Metrics, which enabled it to focus on 41 triggers that could prevent or identify an adverse event, such as abnormal lab results or whether a patient had to be transferred to the ICU.
One common concern is how to mitigate kidney damage that might occur from medications that children need for treatment. The electronic trigger tool identified children on three or more medications that are potentially toxic to the kidneys, enabling pharmacists to notify physicians that a patient is at risk and discuss modifying the drug dose, changing medications or stopping medications. The pharmacist also requests that the doctor order more frequent blood tests for rising levels of creatinine, an early sign of kidney damage.
“This allows us to not only intervene but to look for trends and things that might be happening across the system,” says Joann Sanders, chief quality officer. The program has been well received by clinicians as an extra aid in providing safe care, with the understanding, “It’s not Big Brother watching, we know how hard your job is and we’ve got your back,” Dr. Sanders says.