A Focus on Medication Errors and Missed Treatment as an Outcome Measure for Respiratory Care

Background: Recent public concern surrounding ?medication errors? has created both internal and external interest in looking at the topics of ?missed medicated respiratory care treatments? and potential negative clinical outcomes associated with missed treatment. In response to recommendations by the Pharmacy and Therapeutics Committee at Washington Adventist Hospital, Takoma Park MD the Pulmonary Medicine Department created a process for capturing, categorizing, and reporting missed therapy.

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

Results:

Conclusion: Based on the definitions and processes outlined the Pulmonary Medicne Department is in the process of establishing an internal database for benchmarking. Data hase tracked and reported data for 2000 and have baseline aggregate data for 1999. The breakdown of the data based on the established definitions has allowed the department to focus our PI efforts, and we are now able to correlate ?medication errors? with workload, employee performance and customer satisfaction data. The concept of the development of a national definition of ?Respiratory Care Medication Errors? and ?Respiratory Care Medication Occurrences? would be a progressive step for the Respiratory Care profession.