The Science Journal of the American Association for Respiratory Care

2001 OPEN FORUM Abstracts

A Focuson Medication Errors and Missed Treatment as an Outcome Measure for RespiratoryCare

ElizabethBegley RRT MA CPHQ, Christopher Keeys PharD BCPS, Geoffrey Morgan RRT BS, AlfredMunzer MD, Zelick Stewartson RRT BS

Background: Recent public concern surrounding?medication errors? has created both internal and external interest in lookingat the topics of ?missed medicated respiratory care treatments? and potentialnegative clinical outcomes associated with missed treatment. In response torecommendations by the Pharmacy and Therapeutics Committee at Washington AdventistHospital, Takoma Park MD the Pulmonary Medicine Department created a processfor capturing, categorizing, and reporting missed therapy.

Method:Nationally the trend is moving towardthe concept of well-defined definitions for various PI indicators with a centralizeddatabase, such as the JCAHO ORYX program or the Maryland Indicator Project.The concept behind a nationally established PI registry, is that common well-definedindicators can be used for comparisons and benchmarking of outcome data. Inan effort to create a meaningful measure associated with missed therapy theDepartment of Pulmonary Medicine at Washington Adventist Hospital developeda set of defined PI categories for reporting and analyses of Respiratory CareMedication Errors and Missed Treatments.


Total Occurrences4%6.65%
Missed Treatments/ Total Treatments4350 / 98,0003100 / 91,176
MedicationErrors.5% .89%
MedicationErrors / Total Treatments500 / 98,000588 / 91,176
Total # TreatmentsAnnually98, 00091,176


Conclusion: Based on the definitions andprocesses outlined the Pulmonary Medicne Department is in the process of establishingan internal database for benchmarking. Data hase tracked and reported data for2000 and have baseline aggregate data for 1999. The breakdown of the data basedon the established definitions has allowed the department to focus our PI efforts,and we are now able to correlate ?medication errors? with workload, employeeperformance and customer satisfaction data. The concept of the development ofa national definition of ?Respiratory Care Medication Errors? and ?RespiratoryCare Medication Occurrences? would be a progressive step for the RespiratoryCare profession.


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