MOH/S/IPSK/05.08(RR)
This summary is based on:
Additional Information: 1. Avery JV, Sheik A, Hurwitz B, Smeaton L et. al. (2002). Safer medicines management in primary care. British Journal of General Practice; 52 (suppl): S17‐22. 2. Bhasale A. (1998) The wrong diagnosis: identifying causes of potentially adverse events in general practice using incident monitoring. Family Practice; 15(4): 308‐318. 3. Britt H, Miller GC, Steven ID, Howarth GC, Nicholson PA, Bhasale AL, Norton KJ. (1997) Collecting data on potentially harmful events: a method for monitoring incidents in general practice. Family Practice; 14(2): 101‐106. 4. Dovey SM. (2003) Advancing understanding of medical errors in general practice: A discussion of recent research from American Academy of Family Physicians. NZFP; 30(4): 242‐245. 5. Elder NC, Dover SM. (2002) Classification of medical errors and preventable adverse events in primary care: A synthesis of the literature. The Journal of Family Practice; 51(11): 927‐932. 6. Jacobson L, Elwyn G, Robling M and Jones RT. (2003) Error and safety in primary care : no clear boundaries. Family Practice ; 20: 237‐241. 7. Loannidis JPA, Lau J. (2001) Evidence on interventions to reduce medical errors: an overview and recommendations for future research. J Gen Intern Med; 16: 325‐334. 8. Makeham MAB, Dovey SM, County M, Kidd MR. (2002) An international taxonomy for errors in general practice: a pilot study. MJA; 177: 68‐72. 9. Plews‐Ogan ML, Nadkami MM, Forren S, Leon D, Schectman JM. (2004) Patient safety in the ambulatory setting; A clinician‐based approach. J Gen Intern Med; 19:719‐725. 10. Runciman WB, Roughead E, Semple SJ, and Adams RJ. (2003) Adverse drug events and medication errors in Australia. International Journal for Quality in Health Care; 15: i49‐i59. 11. Sanders J, Esmail A. (2003) The frequency and nature of medical error in primary care: understanding the diversity across studies. Family Practice; 20(3): 231‐236. 12. Stelfox HT, Palmisani S, Scurlock C, Orav EJ, Bates DW. The “to err is human” report and the patient safety literature. Quality and Safety in Health Care 2006; 15:174‐178. 13. Stow J. (2006) Using medical‐error reporting to drive patient safety efforts. Association of Operation Room Nurses Journal; 84(3): 406‐420. 14. Wilson T, Sheik A. (2002) Enhancing public safety in primary care. BMJ; 324: 584‐587. 15. Woolf SH, Kuzel AJ, Dovey SM, Philipa RL. (2004) A string of mistakes: The importance of Cascade analysis in describing, counting, and preventing medical errors. Annals of Fam Med; 2(4): 317‐326. Other articles are available upon request This summary was prepared by: Khoo EM, Sararaks S, Lee WK, Sebrina S, Liew SM, Azah AS, Rohana I, Cheong AT, Hanafiah AN, Yusof MI, Lidwina EA, Maimunah AH, Kalsom M, Azman AB. Conflict of interest There is no conflict of interest. Acknowledgement: This document has been peer reviewed by Dr Letchuman Ramanathan, Hospital Taiping and Dr. Nor Mimiroslina Che Omar, Kelana Jaya Health Clinic. This summary should be cited as: Khoo EM, Sararaks S, Lee WK, Sebrina S, Liew SM, Azah AS, Rohana I, Cheong AT, Hanafiah AN, Yusof MI, Lidwina EA, Maimunah AH, Kalsom M, Azman AB. Medical errors in MOH primary care clinics. A Project under the Letter of Intent for Improving Patient Safety. [PC 2; Loi PS 9/2008 (∑13)]. Kuala Lumpur. Institute for Health Systems Research. 2008. Keywords: primary care, clinics, medical errors, management errors, medication, decision making, investigation Evidence Informed Policy Network (EVIPNet) is an The Institute for Health Systems Research international network of partnerships between policy provides scientific evidence to policy makers
Khoo EM, Sararaks S, Lee WK, Liew SM, Azah AS, Rohana I, Cheong AT, Sebrina S, Hanafiah AN, Yusof MI, Lidwina EA, Maimunah AH, Kalsom M, Azman AB. Interim Report: Patient Safety in Primary Care. A Project under the Letter of Intent for Improving Patient Safety. [PC 1; Loi PS 8/2008 (∑12)]. Kuala Lumpur. Institute for Health Systems Research. Research in collaboration with University of Malaya. 2008.
For further information and to provide feedback on this document please contact: Prof Dr Khoo Ee Ming
[email protected] Dr Sondi Sararaks
[email protected] [email protected]
Who is this for?
• • •
This is a collaborative project with
and health managers at every level, to enable them to make evidence-based decision making on health matters. www.ihsr.gov.my
makers, researchers and civil society in low and middleincome countries that support the use of research evidence in health policy-making. www.who.int
The Patient Safety Council and its secretariat Public Health Division, Ministry of Health Primary Care Practitioners
Purpose of this summary
Project reference number: Patient Safety:NMRR-07-768-1040; Primary Care: NMRR-07-770-1042
RESEARCH HIGHLIGHT IPSK/HO/602/003/002(26)/2 of 2008/Σ2 Letter of Intent for Improving Patient Safety: Primary Care
Institute for Health Systems Research
Research Highlight
Baseline results of a study conducted in 12 MOH primary care health clinics reported. 1753 medical records were reviewed by expert panels of are Family Medicine Specialists. These patients could have been seen by medical assistants or doctors. Errors detected were quantified and classified as either diagnostic or management errors. Management errors were further categorized into investigation, medication or decision‐making error. Each error detected was also assessed for preventability and the likelihood to result in serious morbidity or mortality. An intervention package was subsequently introduced consisting of training, audit, pharmacy safe‐netting, formatted medical record forms and educational materials. The study is currently in the phase of a post intervention review to determine its effectiveness. The results are expected to be ready early 2009.
Research Highlight
Method
To inform policy makers, stakeholders and primary care practitioner about the extent and types of medical errors occurring in MOH primary care health clinics and to highlight issues necessitating policy and practice interventions.
MEDICAL ERRORS IN MOH PRIMARY CARE CLINICS Issue Medical errors* are occurring unnoticed in MOH primary care clinics and this may pose important implications on patient safety issues. More than 50% of medical records reviewed had a medical error and almost all (93.4%) of these errors were preventable. Immediate action needs to be taken to uphold our standards of care. This is the baseline results of a study done on patient safety in 12 MOH primary care clinics in 4 states of Malaysia. An intervention package designed based on the baseline findings has been carried out and a post intervention survey is currently being conducted. Key Messages • A high percentage of medical errors, o 57.2% occur in primary healthcare visits o 93% of medical errors were deemed preventable • The majority of medical errors are related to medication • A lack of knowledge and skills of MOH staff has been shown to contribute to medical errors • There is a need to improve the quality of healthcare services provided by MOH health clinics
Funded by: Ministry of Health, Malaysia
* Medical errors = Diagnostic errors, investigation errors, medication errors and decision making errors
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ihsr
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Medical Errors in MOH Primary Care Clinics
3
Background To date, no published data are available on medical errors that occurred in MOH primary healthcare settings in the country. Primary care is most often the first point of contact for patients seeking treatment from health care providers. The recent move by the MOH to shift care of chronic diseases such as diabetes and hypertension to primary care settings means that there will be more patients seeking treatment at primary care clinics compared to previously. The increasing workload coupled with shortened consultation time necessitates greater efforts on the primary healthcare providers to ensure the quality of care provided to patients is not compromised. This study aims to determine the extent of medical errors that occurred in MOH primary care health clinics and to develop a feasible intervention to overcome this. Medical errors as defined in the study: • Medical errors were categorized as diagnostic or management errors. • A diagnostic error is an error that occurs in the making of a diagnosis, usually from history and physical examination. • A management error is an error that occurs in the management of a patient during investigation, treatment and making decision. Key Considerations for Health Care Providers/ Key Considerations for Decision Makers Practitioners • Need to facilitate the use of • Need to adhere to Clinical Practice Guidelines Clinical Practice Guidelines at • Need to constantly update knowledge and primary care enhance clinical skills • Need to ensure non‐evidence • Need to avoid the use of non‐evidence based based medications/ treatments treatment are not practiced • Need to ensure legibility in documentation and prescriptions • Need to strengthen surveillance and audit activities • Need to ensure that documentation of medical records are complete
Key findings Diagnostic error: 3.90% (inconclusive* = 61.80%) Management error: 53.30% (inconclusive = 14.30%) o Investigation error: 21.70% (inconclusive = 22.10%) o Medication error: 41.30% (inconclusive = 27.60%) o Decision‐making error: 14.90% (inconclusive = 39.50%) (“Inconclusive” was often due to incomplete or poor documentation) Detailed findings • 39.8% (CI 26.6‐53.0%) of errors were likely to cause serious morbidity or mortality • 93.4% (CI 83.6‐100%) of errors had strong evidence for preventability • 29.0% (CI 19.5‐38.6%) of errors were due to some form of missing documentation whereby: o 54.7% (CI 43.8‐65.6%) had no documentation of physical examination o 49.5% (CI 38.8‐60.2%) had no documentation of history o 43.0% (CI 27.6‐55.1%) had no documentation of problem or diagnosis • 22.6% (CI 12.8‐32.4%) of errors were due to illegibility • Medical assistants saw 81% of total records assessed. Types of medical errors found • Medication errors were the commonest type of error found. o The most frequent medication error was inappropriate medication given such as prescription of drugs that were not indicated for a condition (e.g. antibiotics for viral fever, antibiotics for conjunctivitis), antacids prescribed with NSAIDs, prescribing of drugs contraindicated in children, prescribing non‐evidence based drugs (e.g. vitamin C for URTI, prolase for leg swelling) o The second most frequent medication error was related to poor management, including poor disease control and CPGs not adhered to. o Other types of medication errors were:
Table 1: Overall medical error rates for primary care setting* Type of error
Error rate (%)
Wrong dosage and frequency of drug prescribed (e.g. drug dose for child not calculated according to body weight) Drug interaction or adverse drug event (e.g. 2 or more antihistamines prescribed)
• Severe medical errors1 include organ failure no action taken, drug dose not monitored and abnormal investigating result no action taken.
Overall Error Rate
ihsr
Medical Errors in MOH Primary Care Clinics
3 states in Peninsular Malaysia
Inconclusive rate (%)
Error rate (%)
1 state in East Malaysia
Inconclusive rate (%)
Error rate (%)
Inconclusive rate (%)
%
Lower CI
Upper CI
%
Lower CI
Upper CI
%
Lower CI
Upper CI
%
Lower CI
Upper CI
%
Lower CI
Upper CI
%
Lower CI
Upper CI
Diagnostic error
3.9
0.0
15.2
61.8
44.0
79.5
4.9
3.4
6.4
61.6
58.2
65.0
3.2
2.1
4.4
61.9
58.9
65.0
Management error
53.3
35.4
71.3
14.3
0.0
29.4
58.7
55.3
62.1
14.6
12.2
17.1
48.4
45.2
51.6
14.1
11.9
16.3
Investigation error
21.7
5.4
38.0
22.1
5.7
38.5
26.3
23.3
29.4
21.8
18.9
24.7
18.0
15.6
20.5
22.4
19.8
25.1
Medication error
41.3
23.5
59.2
27.6
10.6
44.6
45.3
41.9
48.8
25.6
22.5
28.6
37.8
34.7
40.8
29.5
26.6
32.4
Decision‐making error
14.9
0.0
30.1
39.5
21.8
57.3
15.7
13.2
18.3
44.8
41.4
48.3
14.2
12.0
16.4
34.9
31.9
38.0
*Results based on meta‐analysis This research highlights series is based on on‐going research done by the institute and its collaborators on health system policy issues in Malaysia
1
Requiring patient recall
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