Eliminating Errors in the Hospital

By Grasso, Benjamin C. | Clinical Psychiatry News, February 2007 | Go to article overview

Eliminating Errors in the Hospital


Grasso, Benjamin C., Clinical Psychiatry News


Since the Institute of Medicine released its report "To Err is Human: Building A Safer Health System" in 1999, inpatient medical errors have come under increased scrutiny. The report suggested that 44,000 patients to perhaps as many as 98,000 patients die in the hospital every year as a result of errors.

Because psychiatric hospitalization accounts for about one-quarter of hospital admissions, it's likely that errors occur on inpatient psychiatric units.

This month, CLINICAL PSYCHIATRY NEWS talks with Dr. Benjamin C. Grasso about medication errors in inpatient psychiatry. Dr. Grasso is the author of two reviews on medication errors and patient safety and is in private practice. The reviews were commissioned by the Institute of Medicine/National Academy of Sciences. Dr. Grasso and fellow Harvard Medical School associates Dr. David Bates and Dr. Miles Shore were among the first to call attention to the problem in inpatient psychiatry.

CLINICAL PSYCHIATRY NEWS: Are medication errors prevalent in inpatient psychiatry?

Dr. Grasso: It's reported that medical errors in medical-surgical hospitals may kill more patients than industrial accidents, but little is known about medication errors in inpatient psychiatry.

CPN: What do the data show?

Dr. Grasso: There are some hospital studies from the United Kingdom, the most recent of which found a fairly high rate of errors, with 77% being attributable to prescribing errors.

One of the few published studies of psychiatric hospitals is the one three colleagues and I published in 2003 (Jt. Comm. J. Qual. Saf. 2003;29:391-400). We reviewed the charts of 31 patients in a state psychiatric hospital over a 2-month period. The usual modality of self-reporting errors yielded 9 errors per 1,448 days; however, using an independent chart review, we found 2,194 errors per 1,448 days.

Our study supports the often-stated concern that self-reporting of errors results in substantial underreporting. We also found that 58% of the errors we detected had the potential to cause serious harm.

CPN: I understand that your study was conducted at the Augusta Mental Health Institute, a state psychiatric hospital in Maine. Would the situation likely be different in a private institution?

Dr. Grasso: There are no data to answer your question definitively. In a private hospital there may be more pressure to move patients quickly, which could make errors more likely.

On the other hand, in our study, 66% of the errors we picked up were errors of administration. But our study looked at the administration of medication by medication technicians, not registered nurses. …

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