Learning To Prevent Medical Mistakes In Caring For Stroke Patients

Medical errors and adverse events can happen in patients with stroke, and hospital procedures need to be modified to reduce the likelihood of error and patients getting hurt, according to a study published in the February 20, 2007, issue of Neurology®, the scientific journal of the American Academy of Neurology.

For the study, researchers analyzed provider-reported adverse events and errors within a voluntary and mandatory event reporting system in stroke patients admitted to Strong Memorial Hospital at the University of Rochester Medical Center in Rochester, New York, between July 2001 and December 2004. Adverse events are defined as an injury to a patient occurring during medical management, not necessarily because of an error. Medical errors are defined as incorrect actions or plans that may or may not cause harm to a patient.

Of the 1,440 stroke patients studied, 12 percent, or 173 patients, experienced an adverse event. A total of 201 events were reported for the 173 patients. "Learning about what caused these events is the only way to keep them from happening again," said study author Robert G. Holloway, MD, MPH, with the University of Rochester Medical Center, and Fellow of the American Academy of Neurology.

Of the total 201 events reported during the study, 18 were near misses, which are defined as an error that does not reach the patient, and 183 were adverse events.

Of the 183 adverse events, 86 were preventable, 37 were not preventable, and 60 were indeterminate. Of the preventable adverse events, 37 percent were transcription/documentation errors, 23 percent were failure to perform a clinical task, 10 percent were communication/handoff errors between providers, and 10 percent were failed independent checks/wrong calculations.

"Although most patients who experienced a preventable adverse event were not seriously harmed, adverse events do lead to temporary discomfort, longer hospital stays, and in some cases, serious injury, or the potential for legal action," said Holloway. "If these figures were applied to the nearly one million patients admitted to U.S. hospitals each year for stroke, 50,000 to 100,000 patients may experience an adverse event related to an error."

Holloway says as a result of this information, Strong Memorial Hospital has improved its patient care, now uses safer equipment to deliver medications, and a variety of new procedures, including check sheets at the point of patient transfers to make sure no information is lost.

"What this study represents is our hospital's commitment to patient safety," said Holloway. "Along with 3,000 other hospitals, we are part of a national campaign led by the Institute for Healthcare Improvement to improve patient safety and save five million lives from medical errors and adverse events."

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