Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Medical Errors. Myth or Reality
- Dr José Máximo Carles Zerquera, Dr Rubén Rodriguez Rodriguez Professor Anaesthesiologyst, Dra Grace A de Lara García Professor Inmunologyst, Dra Mabel Conde Saura Professor Ophthalmologyst (15 February 2008)
-
Medication errors: Interdisciplinary work can help?
- Aldo Alvarez-Risco, Jose Juarez-Eyzaguirre (18 February 2008)
-
There is also an increased rate of procedural error among residents with poor mental health but no correlation between burnout and procedural errors.
- Yasuharu Tokuda, Hidehito Horinouchi, Tsuguya Fukui (19 February 2008)
-
Junior doctors find errors, not just make them.
- Phillip J. Colquitt (19 February 2008)
-
Re: Junior doctors find errors, not just make them.
- GEORGE Y CALDWELL, SINGA[PORE 259858. (20 February 2008)
-
Re: Re: Junior doctors find errors, not just make them.
- Phillip J Colquitt (21 February 2008)
-
response from a junior doctor
- Aitzaz Bin Sultan Rai, Saima A. Mughal (21 February 2008)
-
Re: response from a junior doctor
- Anindya Niyogi, London E15 4EJ (24 February 2008)
-
Needs more guidelines for working hours for junior doctors
- Om Prakash (25 February 2008)
-
Re: Needs more guidelines for working hours for junior doctors
- Anindya Niyogi, London SW10 9NH (26 February 2008)
-
Re: Re: Needs more guidelines for working hours for junior doctors
- Aitzaz Bin Sultan Rai, Saima Amin Mughal (26 February 2008)
-
Re: Medication errors: Interdisciplinary work can help?
- Mair Rh Martin (3 March 2008)
-
The Journey from ill to well is bumpy
- Dharmagadda Sreedhar, Virendra SL, Manthan J, Udupa N (4 March 2008)
-
Medication errors by Trainee Doctors
- Sath Nag (7 March 2008)
-
Medical errors and chain of events
- khalid alkhouly (7 April 2008)
|
|
|||
|
Dr José Máximo Carles Zerquera, Professor Internal Medicine General Hospital Trinidad. Cuba, Dr Rubén Rodriguez Rodriguez Professor Anaesthesiologyst, Dra Grace A de Lara García Professor Inmunologyst, Dra Mabel Conde Saura Professor Ophthalmologyst
Send response to journal:
|
Dear James McLay and Sarah Ross, We were extremely pleased by your article on medication errors by junior doctors, published in the BMJ on February 7th, 2008. Our hospital recently held a symposium on guidelines for sound medical practices. Several lectures were given at this event and one of them was about medical errors. The possibility of medical errors constitutes a permanent threat in our work as physicians. It is an old problem yet it is also a present topic of interest due to its repercussions on the quality of health care worldwide. The occurrence of adverse events caused by medical errors ranges between 2.5 and 27% according to various reports. In Cuba no megastudies with a solid scientific base have been carried out on this subject. There are several areas of medical assistance in which errors are likely to occur: in diagnosis procedures, in diagnosis means, in therapeutical procedures or expressing a prognosis. There are many risk factors related to medical errors, we list just some of them: Burn-out syndrome, excessive self-confidence, hesitation, routine, wrong diagnosis, use of the new technologies, faulty drug vigilance, outdated standards and procedures, illegible handwriting. The consequences for a patient are well defined: those that do not threaten life, those that may lead to serious conditions threatening the quality of life or life itself, or those that cause death directly or not. In our hospital, a series of controls have been implemented to monitor the quality of the medical attention, which help us in the process of error detection, such as: analysis of medical records, implementation of a committee on drugs and therapies, implementation of a committee on infections, another to assess the quality of surgical procedures, hospital mortality, medical audit. Such errors must be known and analysed in strictly medical meetings deeply enough to gain in experience and then avoid their repetition. It would be very useful for young physicians to apply the clinical method in daily practice. On the other hand, our experience and performance as part of a team will guarantee a continuos professional growth for both experienced and young practitioners. Competing interests: None declared |
|||
|
|
|||
|
Aldo Alvarez-Risco, Professor of Pharmaceutical Care Faculty of Pharmacy and Biochemistry San Marcos University, Jose Juarez-Eyzaguirre
Send response to journal:
|
It is very important to describe medication errors as system failure and not as individual mistakes. In our experience, some medication errors can be avoided if physician and pharmacist work closely together. In the literature we have evidence of the positive impact of collaboration between physician and pharmacist in daily activities. In Peru, 3 main hospitals have a work between pharmacy internships and medical internship and physicians and can offer "2 additional eyes" for issues related to pharmacotherapy. Some studies have been developed in our country for heart failure and they obtained positive outcomes so we believe it is necessary to establish usual situation of medication error in order to create a protocol which will be used by physicians and pharmacists daily for their patients. These initiatives should start even in classrooms to facilitate understanding of the roles of both health professionals in the care of patients. Competing interests: None declared |
|||
|
|
|||
|
Yasuharu Tokuda, Deputy Director Center for Clinical Epidemiology, St Luke's Life Science Institute, Tokyo 104-8560 Japan, Hidehito Horinouchi, Tsuguya Fukui
Send response to journal:
|
Fohrencopf et al have noted a higher rate of medication errors in depressed residents than in their non-depressed peers. But it is also noted that there was no correlation between burnout and medication errors. Since procedure-related error (e.g., an error in central line placement, lumber puncture, and tracheal intubation) is another important type of medical errors, it is also important to examine the relations of depression and burnout to procedural error. In our recent study for measuring self-reported procedural error rate based on prospective daily online reports by medical residents at a teaching hospital in Japan (1), we have also noted an increased rate of procedural error among residents with poor mental health but no correlation between burnout and procedural error. Burnout can be considered an early symptom for poor mental health and it may not yet be at risk for an increased medical error for itself. Therefore, rigorous efforts are needed to implement preventive measures to deteriorating mental health from burnout to clinical depression among medical trainees. References (1) Horinouchi H, Tokuda Y, Nishimura N, Terai M, RN; Takahashi O, Ohde S, et al. Influence of Residentsf Workload, Burnout, Quality of Life, and Job Satisfaction on Procedural Error in a Japanese Teaching Hospital: A Prospective Observational Study Based on a Daily Questionnaire. General Medicine 2008; 9(1): (in press). Competing interests: None declared |
|||
|
|
|||
|
Phillip J. Colquitt, Technician/RN Independent Comment based on hospital experience.
Send response to journal:
|
Editor, In studying medication errors caused by junior doctors[1], it is easy to overlook the counterbalancing effect of medication errors detected by junior doctors. A junior doctor recently informed me that a patient "complained" that potassium was given them by the nurse, in both the Slow k and the effervescent form. The junior doctor then noticed that the document folder containing prescribed medicines, which resides in a purpose designed cradle at the foot of the bed, was numbered for another bed - not the bed the patient was in. All bed document folders are exteriorly labeled in several places with pre-printed labels indicating the bed number to eliminate such misplacement. A phrase label is used in preference to a number - for example "Bed 66" preferred over "66" as numbers can be misread upside down, whereas a phrase orientates the label. It transpired junior doctors guess was right, and potassium intended for another patient had been prescribed, signed for[initials are used] by the RN, and not otherwise detected. The patient's potassium was tested as high, and the intended patient's latest potassium result was low. It further transpired that a verbal directive had been issued to give the potassium by another junior doctor, who simultaneously correctly prescribed it, but there was confusion about which patient was being referred to. The bed document folder was taken as indicative simply because it was attached to the patient's bed. Authoritative, unambiguous, and permanently marked bedside document folders can assist junior doctors in illuminating the source of error. Competing interests: None declared |
|||
|
|
|||
|
GEORGE Y CALDWELL, GENERAL PRACTITIONER 31 BALMORAL PARK, #18-33,, SINGA[PORE 259858.
Send response to journal:
|
Far better to let those "Junior Doctors" enter a good General Practice as soon as they have passed their Finals examination, instead of getting into trouble in the Hospitals. This was the practice up to 1952. After that date those Junior Doctors were used as "cheap Forced Labour" as Housemen which was unfair to most. In General Practice they will learn care and attention and how to prescribe simply under supervision by their peers, and their patients. They will cause little or no harm. Much later, after some four or five years and with some maturity will they return to Hospital practice and be better able to understand the background and concerns of their patients. They will be able to "communicate" with them. "Communication Skills" are learnt in practice not from books at university. Competing interests: None declared |
|||
|
|
|||
|
Phillip J Colquitt, Technician/RN Independent Comment
Send response to journal:
|
I am finding sympathy with your idea as time progresses. This "trial by fire" leading to "learning through mishap" way of training doctors seems entrenched in hospitals. Yet, I continue to remain vigilant in identifying the patient. If only I could find that bedside document folder. Competing interests: None declared |
|||
|
|
|||
|
Aitzaz Bin Sultan Rai, House Officer Oncology department,Allied Hospital, Faisalabad, Saima A. Mughal
Send response to journal:
|
I really appreciate that this issue has been raised. But the reasons given don't fully cover the situation in third world countries like pakistan. i can safely say about my country(Pakistan) that junior doctors are not only "OVERWORKED" but also grossly "UNDERPAID". The salary given to postgraduate trainee in pakistan is less than 250 USD or 120 Pounds. This is uniform salary given to all postgraduate trainees thoughout the country. As a result, they have to work extra hours in private setup just to survive and support their families. Though no such study has been conducted here but most of the trainees do 1-2 private jobs in addition to their regular working hours at hospitals. The stress of work, low pay, demoarlising attitude of senior doctors are just few more factors in addition to those which my senior colleagues have stated One big factor is also that most medical students have "bookish" knowledge when coming to wards after graduation as most of medical schools dont have a problem based learning programs. So these fresh graduates find it difficult to face the practicalities of clinical medicine with just "bookish" knowledge. Competing interests: None declared |
|||
|
|
|||
|
Anindya Niyogi, Clinical Research Fellow Chelsea and Westminster Hospital, London E15 4EJ
Send response to journal:
|
I appreciate the difference in stress in different parts of the world. After working in both India and UK, I found that though junior doctors are paid £100 a month, it is reasonably sustainable as the accommodation is free for all trainees, standard meal costs 30p and standard bus fare is only 5p. Our private work was voluntary and was to boost our income, very similar to Locum work here. I found the private work very useful to gain confidence, be up-to-date and gain better communication skills. This was because you are more likely to be penalised for mistakes in the private sector and your career may be adversely affected. Most of the prescriptions in India are dispensed by drug outlets; most of them do not have a trained pharmacist. So, they are never crosschecked like prescriptions in UK and prescription errors are likely to be missed. But, the medical representatives of different drug companies regularly meet the junior doctors in the clinics, making them aware of different drugs, their use and their doses. Though all mistakes are more common when the involved individuals are under stress, but, that is not an excuse to compromise patient care. Prescription errors are more likely to happen when a junior doctor prescribes a drug unfamiliar to them. This error can be minimised if all standard text books and clinical teaching sessions include details of medication uses, doses and administration. At the same time junior doctors should be ready to consult the formulary before prescribing unfamiliar drugs. This is irrespective to the part of the world where they are working. Competing interests: None declared |
|||
|
|
|||
|
Om Prakash, Assistant Professor of Psychiatry National Institute of Mental Health And Neurosciences(NIMHANS), Bangalore-29, INDIA
Send response to journal:
|
I appreciate this timely editorial. Though the authors have mentioned several causes for mistakes committed by junior doctors, the conditions are somewhat differ in developing countries. As far as I recall my days in residency, I would find more burnout problems. With wages around 250USD per month and responsibility of inpatient ward with 40 patients in addition to help routine OPD of 100 patients, I would feel at times helpless. I had to work more than 16 hours a day. In these circumstances, the chances of errors would be more. Now I would realize that senior doctors must help their junior colleagues in sharing their workload rather playing the role of administrator. I feel that the appropriate guidelines need to maintain regarding working hours for junior doctors to improve their clinical skills. Competing interests: None declared |
|||
|
|
|||
|
Anindya Niyogi, Clinical Research Fellow, Paediatric Surgery Chelsea and Westminster Hospital, London SW10 9NH
Send response to journal:
|
Working Time Directives do exist in the European Union which restricts average weekly hours to 48hrs. This significantly reduces the time for training and lot of trainees are struggling to keep up with the minimum number of cases required in the logbook by the deanery to complete the training. There should be something in between the excessive hours in Indian subcontinent and limited hours in the EU to facilitate proper training. Competing interests: None declared |
|||
|
|
|||
|
Aitzaz Bin Sultan Rai, House Officer Oncology Department, Allied Hospital Faisalabad, Saima Amin Mughal
Send response to journal:
|
I would completely agree with Dr. Om Parkash that there should be "Cap" on maximum number of patients attended by a resident in developing countries like India and Pakistan and maximum working hour guidelines should be strictly followed. Though not a rule a fresh dcotor and post graduate trainee has to be in hospital for atleast 60-70 hours and with that much hectic routine they have to do private jobs addionally.With that much burden of work burn out is not unusual. In some surgical center, there is a concept of what is called a "ward week" where a trainee has to be in the ward for thee whole week. Though they find out time to relax still there can be errors from mental stress and exhaustion. And i will not agree with the anindiya's view that pharmaceutical company representatives "Educate" doctors. Infact , most of the time they are there for "Me TOO" Drugs and use different "marketing tactics" just to increase their revenue for their company. Moreover , the inflation has played its part and 100 Pounds is not a reasonable income anymore. Just to give you an idea the engineers and computer scientist at entry level are being paid atleast 10 times more than junior doctors who spend the sleepless nights in medical school and hospitals.This cannot be an excuse but it does have a demoralising influence when young doctors compare themselves with their peers in other professions. Competing interests: None declared |
|||
|
|
|||
|
Mair Rh Martin, Medicines Information Pharmacist Ysbyty Gwynedd, North West Wales NHS Trust Bangor Wales LL57 2PW
Send response to journal:
|
Interesting your comments about interdisciplinary working to reduce medication errors. In many hospitals in the UK there is work going on with pharmacists training medical students and junior doctors in safe prescribing. One example ties in with the NPSA alert on making Anticoagulation safer. This is a high risk area in which juniors have told us that they do not feel confident in prescribing. Rather than all doing the same thing in different hospitals it would make more sense for this training to be joint training in undergraduate courses. Which brings me to the point really - there has been much talk of running some pharmacy and medicine courses jointly for some topics, in the undergraduate years. Reducing medication errors would be one good reason to do this. The sooner the better... Mair Martin Medicines Information Pharmacist Competing interests: None declared |
|||
|
|
|||
|
Dharmagadda Sreedhar, Lecturer Manipal Collegeof Pharmaceutical Sciences, Manipal University, Manipal, Virendra SL, Manthan J, Udupa N
Send response to journal:
|
Article by James McLay and Sarah Ross would definitely contribute in its own way to minimize the medication errors. The journey from ill to well is long and filled with various areas where errors can occur. Rightly mentioned by Dr José Máximo Carles Zerquera et al that there are several areas of medical assistance in which errors are likely to occur. Medication error would be rectified if identified earlier in case of inpatients but it would be difficult to recall the outpatient to rectify the same. It is true that medical errors would occur due to Burn-out syndrome, excessive self-confidence, hesitation, routine, wrong diagnosis, use of the new technologies, faulty drug vigilance, outdated standards and procedures, illegible handwriting but one should think the consequences of the same. Medical profession is said to be pious and one should make up their mind that whether they would be able to do justification to the profession. Medical profession is considered to be one among well respected professions and also has an emotional touch as the patients consider Doctor as god who saves their lives. Doctor should not give an excuse for the medical errors let it be a junior or a senior or an experienced doctor. Minimizing medication errors is a continuous process where the responsibility lies in the hands of Physician, the first person contacted by patient, has to ensure that medicine or the treatment regime opted for the patient is right, the nurse, timely notice and reporting of the error would save the patient life and last but not the least the pharmacist, who actually dispense the medication should always clarify with the physician to avoid the dispensing the wrong medicine and should report any drug-drug interactions with medicines mentioned in the prescription. Competing interests: None declared |
|||
|
|
|||
|
Sath Nag, Consultant Physician, Acute Medicine, Diabetes & Endocrinology James Cook University Hospital,Middlesbrough TS4 3BW
Send response to journal:
|
Depression and burnout in Junior Doctors may well account for some of the prescribing errors noted in hospitals but given the wide differences in the prevalence of depression, other factors are clearly relevant. In the United Kingdom, Modernising Medical Careers (MMC) has fragmented the time that a junior doctor will spend with a Speciality firm. These hapless souls have to move on after a brief stint to another specialty before any knowledge is consolidated and applied clinically. An unpalatable fact is that basic pharmacology knowledge in most trainees is sadly abysmal and ‘on the floor’ supervised teaching and prescribing is the only way to get trainees up to speed and confident about prescribing drugs safely. Pharmacists on the Acute Assessment Unit and other wards are an invaluable resource and have a critical role in education. Insulin prescribing is one area fraught with the potential for serious errors to occur. A lack of practical knowledge and general guesswork underpins most of these common mistakes which include prescribing intermediate and long acting insulin multiple times a day, the inappropriate use of insulin infusions that result in severe and prolonged hypoglycaemia and prescribing oral hypoglycaemic drugs at the wrong time which often results in catastrophic hypoglycaemia particularly in the elderly. The frequency with which these errors occur suggest they are more than just anecdotal incidents. The rapid turnover of Junior Doctors inevitably means that in- house education sessions across specialties will have to be run more frequently to accommodate all trainees. This will ensure trainees develop a working knowledge of therapeutics that is structured and safe. Common sense however has to prevail and the general adage ‘If you don’t know, Ask’ has never been truer. Competing interests: None declared |
|||
|
|
|||
|
khalid alkhouly, General Surgeon 10 Woodland Hill, Perth Andover, NB, E7H 5H5
Send response to journal:
|
We sometimes forget that we were junior at one stage, and we did more or less the same mistakes. However, it is our duty not only to find out why these medical errors happened but also to fix all and give those junior a better chance of learning under close supervision. The majority of healthcare staff is highly motivated individuals who work together as a team to achieve the best outcomes for their patients. Health professionals have put in place a range of systems and checks to prevent errors. Periodic healthcare system review limits the incidence of error, so that if an error occurs its damaging effects are minimized. However, recent experience has shown that in certain situations those safeguards have not been adequate and have failed to prevent serious error and harm to patients. Errors may occur when both human and system factors interact in a chain of events. Too often it is only the actions of individuals. Trigger factors within the workplace should also be considered. Many healthcare organizations have developed their own systems for reporting and reviewing errors to raise awareness of risks. However, these developments have not been integrated to establish disseminating the lessons learnt and changes implemented. Too often, incident enquiries have been characterized by passive learning –where lessons are identified but not carried through into practice. Since we have the efficient and effective organizations, our projects should focus on education. Audiences include patients, providers, and policymakers. A more open culture, in which errors can be reported and discussed, mechanisms for ensuring the lessons are put into practice. Mistakes do occasionally occur and in the great majority of cases the causes of serious errors stretch far beyond the actions. Learning organization must be locally driven by health professionals and managers at the front line of patient care. Competing interests: None declared |
|||