Improving the identification and management of chronic kidney disease in primary care: lessons from a staged improvement collaborative

Objectives To (i) compare medication errors identified at audit and observation with medication incident reports; (ii) identify differences between two hospitals in incident report frequency and medication error rates; (iii) identify prescribing error detection rates by staff. Design Audit of 3291patient records at two hospitals to identify prescribing errors and evidence of their detection by staff. Medication administration errors were identified from a direct observational study of 180 nurses administering 7451 medications. Severity of errors was classified. Those likely to lead to patient harm were categorized as ‘clinically important’. Setting Two major academic teaching hospitals in Sydney, Australia. Main Outcome Measures Rates of medication errors identified from audit and from direct observation were compared with reported medication incident reports. Results A total of 12 567 prescribing errors were identified at audit. Of these 1.2/1000 errors (95% CI: 0.6–1.8) had incident reports. Clinically important prescribing errors (n = 539) were detected by staff at a rate of 218.9/1000 (95% CI: 184.0–253.8), but only 13.0/1000 (95% CI: 3.4–22.5) were reported. 78.1% (n = 421) of clinically important prescribing errors were not detected. A total of 2043 drug administrations (27.4%; 95% CI: 26.4–28.4%) contained ≥1 errors; none had an incident report. Hospital A had a higher frequency of incident reports than Hospital B, but a lower rate of errors at audit. Conclusions Prescribing errors with the potential to cause harm frequently go undetected. Reported incidents do not reflect the profile of medication errors which occur in hospitals or the underlying rates. This demonstrates the inaccuracy of using incident frequency to compare patient risk or quality performance within or across hospitals. New approaches including data mining of electronic clinical information systems are required to support more effective medication error detection and mitigation.

[1]  N. Stanhope,et al.  An evaluation of adverse incident reporting. , 1999, Journal of evaluation in clinical practice.

[2]  B. Franklin,et al.  The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study , 2007, Quality and Safety in Health Care.

[3]  S de Lusignan,et al.  Chronic kidney disease management in the United Kingdom: NEOERICA project results. , 2007, Kidney international.

[4]  S. de Lusignan,et al.  How ready is general practice to improve quality in chronic kidney disease? A diagnostic analysis. , 2010, The British journal of general practice : the journal of the Royal College of General Practitioners.

[5]  David W Bates,et al.  Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. , 2002, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[6]  David C Classen,et al.  Improving medication safety: the measurement conundrum and where to start. , 2003, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[7]  Sue M. Evans,et al.  Attitudes and barriers to incident reporting: a collaborative hospital study , 2006, Quality and Safety in Health Care.

[8]  D. O'donoghue,et al.  A collaborative project to improve identification and management of patients with chronic kidney disease in a primary care setting in Greater Manchester , 2012, BMJ quality & safety.

[9]  D. Rooney,et al.  Insights from the sharp end of intravenous medication errors: implications for infusion pump technology , 2005, Quality and Safety in Health Care.

[10]  W. Dunsmuir,et al.  Association of interruptions with an increased risk and severity of medication administration errors. , 2010, Archives of internal medicine.

[11]  M. Parchman,et al.  Developing and Running a Primary Care Practice Facilitation Program A HowTo Guide , 2011 .

[12]  Nicolette C. Mininni,et al.  Quality-improvement analytics for intravenous infusion pumps. , 2013, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[13]  C. Pamer,et al.  Retrospective analysis of mortalities associated with medication errors. , 2001, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[14]  H. Rutberg,et al.  Reporting of sentinel events in Swedish hospitals: a comparison of severe adverse events reported by patients and providers. , 2011, Joint Commission journal on quality and patient safety.

[15]  S. Dahrouge,et al.  An overview of practice facilitation programs in Canada: current perspectives and future directions. , 2013, Healthcare policy = Politiques de sante.

[16]  A. Abdelhafiz,et al.  Chronic kidney disease in older people; disease or dilemma? , 2010, Saudi journal of kidney diseases and transplantation : an official publication of the Saudi Center for Organ Transplantation, Saudi Arabia.

[17]  J. Braithwaite,et al.  Effects of Two Commercial Electronic Prescribing Systems on Prescribing Error Rates in Hospital In-Patients: A Before and After Study , 2012, PLoS medicine.

[18]  B. Franklin,et al.  Providing feedback to hospital doctors about prescribing errors; a pilot study , 2007, Pharmacy World & Science.

[19]  S. de Lusignan,et al.  UK Prevalence of Chronic Kidney Disease for the Adult Population Is 6.76% Based on Two Creatinine Readings , 2012, Nephron Clinical Practice.

[20]  Charles Vincent,et al.  Incident reporting and patient safety , 2007, BMJ : British Medical Journal.

[21]  Ann C. Haas,et al.  How event reporting by US hospitals has changed from 2005 to 2009 , 2011, BMJ quality & safety.

[22]  Trevor A Sheldon,et al.  Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review , 2006, BMJ : British Medical Journal.

[23]  Jonathan M. Teich,et al.  The impact of computerized physician order entry on medication error prevention. , 1999, Journal of the American Medical Informatics Association : JAMIA.

[24]  E. McGlynn,et al.  The quality of health care delivered to adults in the United States. , 2003, The New England journal of medicine.

[25]  I. Buchan,et al.  Trends in mortality from 1965 to 2008 across the English north-south divide: comparative observational study , 2011, BMJ : British Medical Journal.

[26]  Peter J. Pronovost,et al.  Improving the Value of Patient Safety Reporting Systems , 2008 .

[27]  David Bamford,et al.  The NIHR collaboration for leadership in applied health research and care (CLAHRC) for greater manchester: combining empirical, theoretical and experiential evidence to design and evaluate a large-scale implementation strategy , 2011, Implementation science : IS.

[28]  David B Nash,et al.  Mandatory State-Based Error-Reporting Systems: Current and Future Prospects , 2005, American journal of medical quality : the official journal of the American College of Medical Quality.

[29]  Albert J. J. A. Scherpbier,et al.  A Comprehensive Overview of Medical Error in Hospitals Using Incident-Reporting Systems, Patient Complaints and Chart Review of Inpatient Deaths , 2012, PloS one.

[30]  David W. Bates,et al.  Incidence and preventability of adverse drug events in hospitalized adults , 1993, Journal of General Internal Medicine.

[31]  Charles Vincent,et al.  Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place , 2007, Quality and Safety in Health Care.

[32]  A Kitson,et al.  Enabling the implementation of evidence based practice: a conceptual framework. , 1998, Quality in health care : QHC.

[33]  J. Neily,et al.  Improving patient safety using the sterile cockpit principle during medication administration: a collaborative, unit-based project. , 2013, Journal of nursing management.

[34]  K Henriksen,et al.  Improving the Value of Patient Safety Reporting Systems -- Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment) , 2008 .

[35]  Peter J. Pronovost,et al.  Underreporting of Patient Safety Incidents Reduces Health Care's Ability to Quantify and Accurately Measure Harm Reduction , 2010, Journal of patient safety.

[36]  Kaveh G Shojania,et al.  The frustrating case of incident-reporting systems , 2008, Quality & Safety in Health Care.

[37]  N. Stanhope,et al.  Reasons for not reporting adverse incidents: an empirical study. , 1999, Journal of evaluation in clinical practice.

[38]  T. Brennan,et al.  Physician Reporting Compared with Medical-Record Review to Identify Adverse Medical Events , 1993, Annals of Internal Medicine.

[39]  E. Fitzgerald,et al.  Irish staff nurses perceptions of clinical incident reporting , 2013 .

[40]  Z. Massy,et al.  Chronic kidney disease as cause of cardiovascular morbidity and mortality. , 2005, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[41]  J. Hodson,et al.  Missed medication doses in hospitalised patients: a descriptive account of quality improvement measures and time series analysis , 2013, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[42]  J. Battles,et al.  Adverse-event-reporting practices by US hospitals: results of a national survey , 2008, Quality & Safety in Health Care.

[43]  J. Westbrook,et al.  Are interventions to reduce interruptions and errors during medication administration effective?: a systematic review , 2013, BMJ quality & safety.

[44]  M. Dixon-Woods,et al.  Can an electronic prescribing system detect doctors who are more likely to make a serious prescribing error , 2011 .

[45]  J. Braithwaite,et al.  Attitudes toward the large-scale implementation of an incident reporting system. , 2008, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[46]  Matthew J. W. Thomas,et al.  Mapping the limits of safety reporting systems in health care —what lessons can we actually learn? , 2011, The Medical journal of Australia.