medical errors driving the need to build a safer health system
DESCRIPTION
It is estimated that 8-12% of the patients admitted in hospitals suffer from adverse events while receiving health care. This presentation describes the different reasons for medical errors and global preventation initiatives.TRANSCRIPT
Medical Errors Driving the Need to Build a Safer Health System
Sowmya Rajagopalan, Senior Research Analyst
Healthcare
August 24, 2010
Frost & Sullivan’s Growth Consulting can assist with your growth strategies
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Today’s Presenter
Sowmya Rajagopalan, Senior Research Analyst
Frost & Sullivan
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Table Of Contents
Medical Errors -Introduction
Hospital Acquired Infection (HAI) –Trends
Prevalence of HAI in Europe
Medication Errors
Surgical Errors
Medical Device Failures
Statistics on Patient Safety
Reasons for Medical Errors and Global Prevention Initiatives
About Frost & Sullivan
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Medical Errors -Introduction
� It is estimated that 8-12% of the patients admitted in hospitals suffer from adverse events while receiving health care.
� Adverse events include
– Healthcare associated infections
– Medication related errors
– Surgical errors
– Medical device failures
– Errors in diagnosis
– Failure to act on results of tests
Adverse events are medical errors
caused during the treatment
procedures that are harmful.
Medical Errors are errors caused during
the treatment procedures which are not harmful.
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Hospital Acquired Infection (HAI) -Trends
Healthcare Associated Infections: Percentage Split by
Type, (Europe), 2008
�Biggest and most threatening form of Adverse Event in healthcare.
�According to studies conducted by ECDC in 2008:
�The average prevalence of Healthcare associated Infections in Europe was 7.1%.
�There were approximately 4,131, 000 affected patients.
�Healthcare associated infection lead to 16 million extra days of hospital stay in Europe.
�Mortality due to Healthcare associated infection was high and almost attributed to 37 000 deaths (and contribution to an additional 110 000).
�The impact of healthcare associated infection on the economy was high as well. It accounted for about Euro 7 billion per year (including direct costs only).
9.9%25.4%
11.0%
23.8%
23.5%6.4%
SkinLower Respiratory TractSurgical WoundUrinary TractBloodOther
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Prevalence of HAI in Europe
Source: ECDC, 2008
U.K 9.0 %
France 6.6%
Italy 4.9%
Norway 6.8 %
Slovenia 4.6%
Switzerland 8.1%
Greece 9.3%
Scotland 9.5%
Average in Europe: 7.1%
Slovenia 4.6%
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Medication Errors
�Second highest in terms of medical error incidence.
�5% of all hospital admissions are due to an adverse drug reaction (ADR)
�ADR is the fifth most common cause of hospital death
�197,000 deaths per year in the EU are caused by ADR.
�The possible errors due to medication are
� Multiple formulations of the same drug leading to confusion
� Confusion caused by packaging and labelling;
� Dosing errors
� Drug administration errors
� Errors in preparing medicines
�Medication errors account for 11% of hospital admissions in the U.K.
� There is an extra annual expenditure of £1.1bn on drug related adverse events, up to 70% of which are preventable.
�The recently created National Patient Safety Agency (NPSA) has been tasked to reduce medication errors by 40%.
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Surgical Errors
� Surgical Errors are errors caused either during surgery or immediately after
surgery.
� Patients injured as a result of operation are 7 times more likely to die while
hospitalized and are likely to be readmitted to hospital within 3 months of
being discharged.
� According to the NHS National Patient Safety Agency, in 2007 there were
129,000 reported surgical errors, which resulted in severe harm to more
than 1,000 patients and the deaths of 271.
� 1 of every 10 patients who died within 90 days of surgery did so because of
a preventable error.
� Types of Surgical Errors
Anesthesia errors Medication errors
Surgical fire Wrong site surgery
Unnecessary surgery Injury during surgery
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Medical Device Failures
� Medical Device Failure accounts for 13 % of all type of adverse events and
is the 3rd largest category.
� Device Failure Types
� 1. Product Defects
� Design defect Manufacturing defect
� 2. Misuse/abuse
Greater loads than expected, finite shelf life, poor healing,
maintenance, adherence to instructions for use (IFU) – hospital,
surgeon, technician
� Among major causes of medical mistakes there are: 15-20% mechanical
failure and 60-80% human error
� 80,000 to 85,000 reports on device problems annually
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Statistics on Patient Safety
� A survey on Medical Errors showed:
– 23% of European Union citizens claim to have been directly affected by medical error,
– 18% claim to have experienced a serious medical error in a hospital
– 11% to have been prescribed wrong medication.
� Evidence on medical errors shows that 50% to 70.2% of such harm can be
prevented through comprehensive systematic approaches to patient safety
� Strategies to reduce the rate of adverse events in the European Union alone
would lead to the prevention of more than 750 000 harm-inflicting medical
errors per year, leading in turn to over 3.2 million fewer days of
hospitalization, 260 000 fewer incidents of permanent disability, and 95 000
fewer deaths per year.
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Reasons for Medical Errors and Global Prevention Initiatives
� A survey conducted amongst surgeons revealed that lack of enough
resources( surgeons, nursing staff), exhaustions and packaging errors,
irregularity in following necessary procedures of prescriptions, lack of
proper communication cause these errors that can cost an individual his life.
� Global Initiatives by WHO: In May 2009, a list of 50 global priority areas for
patient safety research was compiled by WHO Patient Safety
� Areas of Prime importance:
– Maternal and new born care
– Hospital acquired Infection
– Coordination and communication
– Unsafe injection practices
– Unsafe blood products
– Adverse drug events
The world is tomorrow is expected to become safe for Patients.
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Next Steps
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