[UPDATE]: To carry home the challenges of managing and measuring the quality of information at times, Beaumont Hospital have issued the following press statement regarding the issue mentioned below (this statement is copied from the comment below).
STATEMENT BY BEAUMONT HOSPITAL RE OMBUDSMAN’S REPORT
The Office of the Ombudsman issued a report this morning which highlighted a complaint against Beaumont Hospital regarding the circumstances in which an unprescribed dosage of medication was given to a patient. In her press release, the Ombudsman made reference to an audit of the Kardex system at Beaumont. A figure of 4.3% was given for Kardex transcription errors.For purposes of absolute clarity, Beaumont Hospital points out that this audit was of approximately 170 reported medication events over a period of two years. This showed there were seven reports of errors made in the transcription of information between Kardex. This is the 4.3% referred to by the Ombudsman and is not 4.3% of all medications administered. It should also be noted that the audit was not of the hospital’s full Kardex system.
There are approximately 500,000 prescriptions written in Beaumont each year and approximately 4.5 million administrations of medication under these prescriptions.
We thank Beaumont Hospital for the clarification presented and gladly publish it in full. The detail contained in the statement from Beaumont Hospital highlights another impact of poor quality information – the negative publicity and causes of concern that can arise from incomplete information made available to the media.
[/Update]
The Irish Times website carries a story this afternoon of the report by the Ombudsman into medication errors in a leading Irish hospital.
According to the report, Beaumont hospital experienced medication errors in just over 1 in every 25 cases (4.3%) [Note – this figure is clarified by Beaumont Hospital in the update above] The root cause of this error rate would seem to be the way in which medications and medication instructions are recorded, with key information being recorded manually on patient record cards and certain key data (such as frequency of dosage) occasionally being omitted for a variety of reasons. Furthermore, the transcription of information from patient record cards which have been filled up can lead to errors in transcription, resulting in errors in patient medication.[Beaumont Hospital clarification: “this audit was of approximately 170 reported medication events over a period of two years. This showed there were seven reports of errors made in the transcription of information between Kardex. This is the 4.3% referred to by the Ombudsman and is not 4.3% of all medications administered. It should also be noted that the audit was not of the hospital’s full Kardex system.”]
Given the implications of incorrect medication, both in terms of injury or death of patients or, at the very least, the increased duration of stay for a patient arising from treatment errors.
The Institute of Medicine in the US has published figures which show that the cost to the Healthcare system (in 2006 dollars) per incident of medication error was around $8750 per hospital stay. An article on the website FutureHealthCareUS.com quotes other studies which put the cost at just under $6000 per event.
Given the impact on human health and welfare (up to and including risk of death) and the financial impact on already overstretched healthcare systems, avoidable medication errors count as a definite IQ Trainwreck.
This story is incorrect in relation to Beaumont Hospital and was taken down by the Irish Times from its site within approximately an hour of being posted. On behalf of Beaumont Hospital I issued the following press statement on Wednesday 9th July. I would be grateful if you could ensure that your site corrects this at the very earliest opportunity because it is an unnecessary and unwarranted cause of concern for patients attending the hospital and their relatives.
STATEMENT BY BEAUMONT HOSPITAL RE OMBUDSMAN’S REPORT
The Office of the Ombudsman issued a report this morning which highlighted a complaint against Beaumont Hospital regarding the circumstances in which an unprescribed dosage of medication was given to a patient. In her press release, the Ombudsman made reference to an audit of the Kardex system at Beaumont. A figure of 4.3% was given for Kardex transcription errors.
For purposes of absolute clarity, Beaumont Hospital points out that this audit was of approximately 170 reported medication events over a period of two years. This showed there were seven reports of errors made in the transcription of information between Kardex. This is the 4.3% referred to by the Ombudsman and is not 4.3% of all medications administered. It should also be noted that the audit was not of the hospital’s full Kardex system.
There are approximately 500,000 prescriptions written in Beaumont each year and approximately 4.5 million administrations of medication under these prescriptions.
This is perfectly believable, based on my experience with the UK health service.
Recently my son was minutes away from being injected with a vaccine that the doctor claimed was perfectly safe for his condition but preferring to do our own research and quickly reading the complex manufacturers instructions we realised there was an issue the doctor or the clinic had not spotted.
What unfolded was a joke – the clinic lacked the facilities to cope with a serious reaction that was inevitable given the type of injections provided, there was completely different opinions on agreed practice between clinic owner, nurses and doctor, and the correct procedure had not been followed because the doctor was fairly new.
Eventually we got an apology because the situation was very close to being a serious problem but we were more concerned about all the other kids who would come after our child.
The problem was classic IQ mis-management.
The clinic posted out a questionnaire months before that the parents filled in and brought on the day, this was used to gauge what procedure to follow in the event of special cases eg. allergies etc.
What we discovered was the questionnaire was incomplete and the clinic themselves claimed that “most people forget anyway”, so there was clearly no IQ controls to ensure that the carer completed the form correctly.
After I calmed down I explained a simple new approach which would take all of 60 seconds to complete and guarantee no more kids would go through what our child did. It was so simple it was laughable but they rang me that night to say it was being introduced.
The lesson in all this as ever is that IQ management is not about tools and technology but common-sense approaches with appropriate governance and stewardship.
The clinic had singularly failed to govern their process and left it to individuals to fabricate a process that was doomed from inception because there were potentials for failure at every point in the information chain.
Sadly it always seems that it takes someones suffering to allow the flood-gates of common-sense to rush in and rectify a problem that often costs nothing at all to fix but a hell of a lot more when it goes wrong.