Education Program Reduces Medical Errors: Studies Reported at Society of Critical Care Medicine's 32nd Critical Care Congress

1/30/2003

From: Katie Lundberg for Society of Critical Care Medicine, 847-827-7502

SAN ANTONIO, TX., Jan. 30 -- Identifying areas of weakness and then educating medical personnel on those topics can improve patient safety, according to two studies released today at the 32nd Critical Care Congress of the Society of Critical Care Medicine.

Fiona H. Levy, MD, medical director of the pediatric intensive care unit (ICU) and medical director of quality management at St. Louis Children's Hospital, reports that after conducting a mandatory seminar on mechanical ventilation, significant improvements were found in ICU performance and patient safety-and those improvements continued for at least six months.

"The study results were reassuring and affirming. We were able to decrease ventilator-associated medical errors by identifying mechanical ventilation as a weakness and designing a ventilator education and communications seminar for ICU nurses and respiratory therapists," she says.

Dr. Levy, lead author of the Washington University School of Medicine study, "The Use of an Education Program to Prevent Ventilator-Related Deaths and Injuries," presented the findings at the Critical Care Congress at the Henry B. Gonzalez Convention Center in San Antonio.

In a companion study, "A New Error Reporting Tool in a Pediatric Intensive Care Unit," also presented at the Congress, Dr. Levy announced that a newly developed paper-based, portable tool to identify medical errors and unintended events was able to identify more weaknesses than a computerized risk management system.

During the first 13 months of implementation, this new error-reporting system found 1,811errors. Of these, 1,067 were deemed serious possessing the potential or having caused patient harm. During the same period of time the standard risk management tool found only 439 (41 percent). Medication errors and patient care errors were the most frequently reported. In the patient care category, errors involving mechanical ventilation dominated. This finding, as well as an alert from the Joint Commission on Accreditation of Healthcare Organizations, indicated ventilation safety as an area that needed improvement.

"Not only have we developed an educational program that has proven to be effective and has external validation, we have also developed an error-reporting tool that can pinpoint areas for improvement within an ICU," says Dr. Levy, an associate professor of pediatrics at the Washington University School of Medicine in St. Louis.

To measure the effectiveness of the ventilator educational program, the researchers studied 100 randomly selected charts for ventilator documentation opportunities both before and after the educational intervention.

They found that documentation of critical mechanical ventilation parameters increased from 17 percent before the educational program to 77 percent afterward. Changes on ventilation records were recorded 100 percent of the time on the nursing flow sheet following the educational intervention, compared to 90 percent previously. Records of ventilation settings at the time of arterial blood gas testing were present in 84 percent of records post-testing versus 63 percent pre-education.

"Tracking medical errors and unintended events and looking at the processes that lead to them can be constructive. You can create positive results by looking at negativity," comments Dr. Levy. "The pediatric ICU staff was able to evaluate our ICU and develop the educational seminar ourselves without costly outside consultation." Washington University is now using the error-reporting tool to spearhead other process-improvement projects in other parts of the hospital to improve patient safety.

Dr. Levy cites information that between 44,000 and 98,000 people die each year in the United States as a result or medical errors.

"These data can be used to devise a process improvement study, act on it and get results. I think it has global implications," she concludes.

------ The Society of Critical Care Medicine is the leading professional organization dedicated to ensuring excellence and consistency in the practice of critical care medicine. With over 10,000 members worldwide, the Society is the only professional organization devoted exclusively to the advancement of multidisciplinary, multiprofessional intensive care through excellence in patient care, professional education, public education, research and advocacy. Members of the Society include intensivists, critical care nurses, critical care pharmacists, clinical pharmacologists, respiratory care practitioners and other professionals with an interest in critical care, which may include physician assistants, social workers, dieticians, and members of the clergy.