PAMEAS is dedicated to reducing medical errors and improving patient safety through patient advocacy in education and training of healthcare providers and patients.
  • Whatever other advances we make in healthcare, we must strive to eliminate the scourge of medical errors, which is the third leading cause of death in America after heart disease and cancer. 
  • Ten percent of all U.S. deaths are now due to medical errors.
  • More than 250,000 people each year, 700 per day, 30 per hour, one every 120 seconds die needlessly.
  • They died because someone made a mistake or some process was faulty.
  • Many deaths could have been avoided if the victims, the patients, had been more empowered in their care.
  • PAMEAS focuses on reducing medical errors in ways that are reflected in the advocacy and empowerment of patients.

     

PAMEAS Programs focus to Reduce Medical Errors 

  1. Reducing Medication Errors
    1. Acknowledge that there is a problem with medication errors in the facility. Today, there is always a problem with medication errors in a facility.
    2. Use standardized order sets
    3. Put in place a system that requires double-checking to reduce medication administration errors
    4. Get pharmacists more directly involved in patient treatment
    5. Be innovative in developing best practices
    6. Monitor, measure, and evaluate clinical practices
    7. Be committed to patient safety - it must be seen as important as the quality of care, outcomes, and finances.
    8. Never depend on hand-written orders
      • Use standardized medication order entry
    9. Ensure clear and complete instructions are dispensed with all medications
    10. Pay close attention to the patient's critical diagnoses (e.g., kidney, liver, psychiatric diseases, and diabetes mellitus) which can affect not only the selection of medication but also dose and frequency
    11. Repeat the order when calling prescriptions into a pharmacy for a patient
    12. Have regular live or online in-service programs to keep providers current on new information relating to prescription medications and their effects
    13. Store "high alert" or similar-sounding drugs in separate areas so they won't be easily confused
      • Make sure the drug storage area is well organized
      • Go through the medication storage area at least quarterly and discard any expired medication and make sure medication labels are easy to read and facing forward on the shelf
    14. Utilize the Institute for Safe Medication Practices (ISMP) list of medications deemed to be "high alert"
      • These medications could cause serious harm if administered incorrectly
      • Care providers should commit these drugs to memory and red-flag them when taking the patient's medication history
    15. Care providers should learn and differentiate drug names that are similar
    16. Require patient identification and drug allergy double-checking
      • Utilize at least 2 identifiers that are specific to the patient before administering medication
      • Ask the patient about allergies and reactions to medications before any new medication is administered
      • Avoid abbreviations, which can be easily misinterpreted when documenting medication allergies
      • Note the patient's current medication regimen and update the list at each doctor's visit
  2. Training of Providers and Staff in Best Practices.
    1. Utilize the latest clinical procedures that improve outcomes, reduce complications, and increase patient satisfaction and comfort
    2. Up-to-date training on medical technologies
    3. Training on patient safety practices
    4. Development of protocols, guidelines, and checklists
    5. Utilization of Situational Simulations and Drills to Improve Clinical Outcomes and Reduce Medical Errors
    6. Training with medical simulators on complex procedures
    7. Develop a structure for handoff conversations
    8. Work to reduce infections by following federal guidelines for disinfecting patient rooms, surgical tools, labs, and other areas
    9. Ensure that providers and staff are following best practices for hand hygiene
  3. Reduce Diagnostic Errors
    1. Utilize practices and systems to reduce mistaken diagnoses, delayed diagnoses, overdiagnosing, and partial diagnoses
    2. Diagnosing patients should involve the entire care team
      • Each person on the team should use their expertise effectively and be supported when they speak up if they see any inconsistencies
    3. Put in place continuous, structured, and systematic procedures that evaluate work performance via peer review to improve diagnostic accuracy
      • Support anonymous feedback and regular reviewer ratings 
      • Utilize peer review software solutions
    4. Deploy AI-based decision support systems
    5. Utilize structured reporting
    6. Put in place systems that ensure consistent follow-up on all diagnosese and resulting treatment plans
  4. Patient Advocacy
    1. Each department must have full-time patient advocates, trained in clinical procedures and there to only represent the patient's interest
      • Best to have retired physicians or nurses in this position
      • Empowered to intervene on behalf of the patient
    2. Aggressive patient education and informed consent
      • The focus should be on empowering the patient
  5. Intelligent Decisions regarding Medical Information Management
    1. Don't be driven with a product focus
    2. Emphasis on open-source, open-standards solutions
    3. Stress ease of use
    4. Information integrity
    5. Cost-effective solutions
    6. Utilize automated solutions to reduce time spent on "paperwork"
  6. Distributed Healthcare solutions
    1. Reducing length-of-stay
    2. Utilization of telemedicine and other appropriate technologies
      • Train personnel to focus on distributed solutions
  7. Appropriate Staffing
    1. Using practice extenders and other alternatives to physicians
    2. Strict limits length of shifts and overtime
    3. workloads that reduce burnout
  8. Patient-Centric Care
    1. Utilizing Complimentary Care Providers on Your Care Team
    2. Encourage patient empowerment and involvement in all stages of clinical decision making
    3. Utilize a Patient Reviewer on all committees (e.g., hospital policy, M&M Boards, departmental practice planning, etc.)
    4. The Concierge Medicine Option for Patient-Centric Care
 

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Medication Errors harm over 1.5 million people per year (low estimates are 400K in hospitals, 800K in long term care facilities, and 300K in outpatients). In addition to increased suffering and loss of life, over $1B in extra medical costs is incurred.

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Clinical Decision Making is a major source of medical mistakes. Perhaps only half of Americans receive the recommended care they need and more than 30% of the care received may be unnecessary.

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Poor Communications cause medical mistakes, contributing to perhaps half of all medical errors. This includes inadequate verbal communications between provider/patient & physician/nurse, poor handoff of patients, improper documentation, illegible handwriting, spelling errors, and unclear medication or procedure instructions.

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Inappropriate Staffing results in poor patient to physician/nursing care ratios. This is due to financial and staffing issues. Use of appropriate technology may help as will changes in business practices and empowerment of patients to seek care remotely, such as with telemedicine solutions.

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Healthcare Complexity contributes to the increasing incidence of medical errors. This can include poor training in complex medical technology, powerful medication administration & management, complicated intensive care environments, and prolonged hospital stays all contribute to error-prone environments.

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Provider risk factors contribute significantly to increasing incidences of medical mistakes.  Sleep deprivation in interns, residents, and on-call staff results in poor decision-making, substandard procedure completion, and errors in judgment. Depression and burn-out are serious risks among providers.

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Diagnostic Errors contribute almost half of all medical mistakes. Nearly every person in America will experience a diagnostic error in their lifetime. There are 18 million primary care diagnostic errors each year that contribute to 10% of inpatient deaths (74,000/year). Five percent of office visits result in a diagnostic error and 12% of hospital adverse events are caused by misdiagnosis.

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Patients must be empowered to work closely with their care providers, asking them questions and understanding their options. They must be encouraged to do this and not treat their physicians as "super beings" that know all the answers. Self-treatment and home care options supported by remote consultations with care providers must be encouraged. Complementary care where appropriate should be explored.