Andrea Righi de Oliveira Kelian
Nurse specialized in Nursing Management, Hospital Administration and Quality Management in Health.
Summary
Among the adverse events (AE) discussed, one of the most concerning is that related to medication errors and, more specifically, those related to medication administration. The study aims to collect scientific data to propose a model for calculating the cost of AEs in Brazil. A bibliographical research of articles published between 1995 and 2014, both national and international, was carried out. Based on the articles, we can propose a model for the minimum estimated cost of AEs related to administration errors. We understand the importance of investing in actions that can mitigate the risk of AEs occurring, instead of having to incur high costs for their treatment.
Keywords: patient safety, adverse events, medication errors, medication system
1. INTRODUCTION
Currently, the issue of medication errors is causing serious problems and raising concerns about the responsibility of providing a safe environment with quality nursing care.
Medication administration is one of the most serious and responsible activities in nursing and its execution requires the application of several scientific principles that underpin the nurse's action, in order to provide patient safety.
Medicating patients depends on merely human actions and errors are part of this nature, however, a well-structured medication system should promote conditions that help minimize and prevent errors, implementing standards, rules, actions, and processes with the purpose of assisting the professionals involved.
Os adverse events related to medications can lead to significant health problems for patients, with significant economic and social repercussions.
The use of medications is one of the most commonly used interventions in the hospital environment. However, studies over the last few years have shown the presence of errors in medication treatment, causing harm to patients ranging from non-receipt of the necessary medication to injuries and deaths (LEAPE et al. 1995; TAXIS & BARBER, 2003). Medication administration is the last opportunity to prevent a medication error that may have already arisen during the prescription or dispensing of medications.
Os Health professionals must be aware and alert to this fact and constantly seek measures to prevent errors through new knowledge, conduct or strategies that aim to protect everyone involved, especially the patient.
Obtaining a broad view of the medication system enables professionals to carry out analysis and interventions that ensure responsible and safe care for the patient and themselves.
Os medication errors are considered adverse events to the medication that can be prevented, which may or may not cause harm to the patient, with the possibility of occurring at one or more moments within the medication process (BATES et al., 1995; LEAPE et al. 1995).
O Institute of Medicine of the USA published in 1999 a book-report entitled: “To Err is Human: Building a Safer Health System” (To Err is Human: Building a Safer Health System).
This mortality attributed to adverse events in health care was a mortality (in the US, at the time of publication) greater than that from automobile accidents (43.458 deaths in one year), breast cancer (42.297 deaths in one year) or AIDS (16.516 deaths in one year), placing deaths from errors resulting from health care as the 8th leading cause of mortality in the US.
This publication also provided data on the estimated costs generated by adverse events over the course of a year in the US: US$17–29 billion per year.
This publication caused a major impact on public opinion in the United States. Then-President Bill Clinton called on federal health agencies to implement the recommendations of the Institute of Medicine.
Data from Brazil, from 2006, approximately 11.000.000 hospitalizations through the SUS (Unified Health System) and 4.000.000 hospitalizations in the private sector, for an estimated total of 15.000.000 hospitalizations in 1 year.
According to these data from Brazilian studies, we would have an incidence of 7,6% of patients with adverse events. We would therefore have 1.140.000 patients suffering adverse events in Brazil per year.
In March 2014, the Ministry of Health, the Oswaldo Cruz Foundation and Anvisa launched the “Reference Document for the National Patient Safety Program”, which also mentions that 10% of patients suffer some type of adverse event and of these 50% would be preventable. This data refers to a study carried out in several countries such as Australia, England, New Zealand, Canada among others, including Brazil. (DE VRIES, 2008)
Patient Safety refers to reducing the risk of unnecessary harm associated with health care (adverse events) to an acceptable minimum. The incidence of patients suffering some type of adverse event while hospitalized can reach almost 17%, depending on the study performed.
These adverse events include: increased hospital stay, temporary or permanent injuries, and even death. It is essential to consider the importance of risk management focused on patient safety.
On the report “To err is human: building a safer health system"To Institute of Medicine (USA) published in 1999, based on studies carried out in Colorado, Utah and New York, indicates that of the 33,6 million hospitalizations carried out in 1997 in US hospitals, around 44.000 to 98.000 Americans died due to problems caused by medication errors (KOHN et al., 2001).
Thus, and based on all the research literature on the subject, we aim to propose a minimum estimated cost model with AE related to management errors.
2. DEVELOPMENT
The results of a study carried out in two large tertiary hospitals, Brighan and Women's Hospital and Massachusetts General Hospital, in the United States of America, indicated an average of 6,5 adverse drug events for every 100 hospitalizations, of which 28% could have been prevented (BATES et al., 1995).
Medication errors can often cause harm to patients and, according to Bates (1996), approximately 30% of harm during hospitalization is associated with medication errors, which also have serious economic consequences for health institutions. It is estimated that approximately US$ 4.700 is spent per preventable adverse drug event, or approximately US$ 2,8 million, annually in a teaching hospital with 700 beds. The annual cost of morbidity and mortality related to medication errors in the USA has been estimated at approximately US$ 76,6 billion (BERWICK & LEAPE, 1999; KOHN et al., 2001, ANDERSON, 2002).
Medicating patients requires an effective communication process for this activity to be carried out successfully. Communication problems can be one of the causes of medication errors, and originate from various situations encountered in the professional's day-to-day life (BARKER & HELLER, 1964 apud RIBEIRO, 1991, p. 70).
It is known that errors are part of human nature, therefore medication systems must be well structured in order to promote conditions that help minimize and prevent errors, planning processes and implementing standards, rules and actions.
A hospital's medication system is open and complex, involving several steps that are interrelated and interconnected by several actions, developing 20 to 30 different steps during the processes of prescribing, dispensing and administering medications, always involving many individuals and multiple transfers of orders or materials, which pass from one hand to another, which can lead to medication errors (LEAPE et al., 2000).
In 1989 the Joint Commission on Accreditation of Healthcare Organizations – JCAHO identified five components or processes of the medication system, namely: selection and obtaining of medication; prescription; preparation and dispensing; administration of medication and monitoring of the patient in relation to the effects of the medication (NADZAM, 1998).
According to a study by INCA (National Cancer Institute) in November 2010, the most common errors in medication administration are inadequate technique, wrong location, inadequate preparation and administration without observing the precautions related to that medication. Errors can result in serious problems for the patient and their family, such as causing disabilities, prolonging hospitalization and recovery time, exposure to more procedures and measures, delay or impediment in resuming their social functions and even death.
The administration of medications can be considered, in a health institution, as a high-risk activity because it is inherent to the daily practice of patient care and because this activity is closely linked to and dependent on human action.
Nowadays, around 88% of patients seeking health-related care receive medication prescriptions. (CASSIANI, 2005).
In a study carried out in several countries, including Brazil, 24 patients in ICUs were observed for 1328 hours in relation to medication administration and found that the most common errors were:
- Wrong dose;
- Wrong medication;
- Wrong way;
- Wrong administration time;
- Absence of administration.
In a total of 1328 patients observed, 24 errors were found in 861 patients over 441 hours, i.e., the same patient suffered more than one error in these 24 hours. In 12 of these, there was permanent damage or death.
In this analysis we can see that of the total number of patients observed, 33% suffered some error in relation to medication administration.
A study by USP, conducted in 2010, analyzed 5 university hospitals and showed that there were 30% of errors in medication administration, of which 77,3% were at the wrong time, 14,4% were at the wrong dose, 6,1% were at the wrong route, 1,7% were in the administration of unauthorized medication and 0,5% were in patient mix-ups. This study analyzed 4958 intravenous dose administrations and 1500 errors.
Within these cited studies, the number of adverse events that could be avoided is close to 60% in the situations described.
If we take into account the deaths and serious injuries that can occur, a lot of suffering could be avoided for the patient and their families.
Based on the articles collected, we can infer a scheme for a better understanding of the data found:
TEACHING SCHEME OF THE STRUCTURE OF ADVERSE EVENTS RELATED TO MEDICATION ERRORS
In the studies surveyed, few materials were found related to the cost of non-quality, more specifically talking about the costs of an adverse event related to medication errors.
Most studies that report amounts spent on adverse events provide a cost calculated in general terms, that is, costs arising from any type of adverse event.
In the 50s and 60s, there were already records of adverse events (AEs) occurring in health services, but it was in the 90s that studies showed the importance of the social and economic costs resulting from these events. Harvard Medical Practice Study (HMPS) estimated that AEs occurred in 3,7% of admissions to acute care hospitals in New York State, United States of America (USA), in 1984. (PORTO, 2010).
The methodology used by HMPS served as a basis for other studies carried out in different countries.
The study carried out by Thomas et al.3 in hospitals in the states of Utah and Colorado, USA, showed that 3% of hospitalizations had AEs, of which 33% (Utah) and 27% (Colorado) were preventable. They estimated that eliminating preventable AEs could save between 17 and 29 billion dollars, including lost income due to inactivity, disability and medical expenses.
The study conducted in the United Kingdom found that AEs occurred in 10,8% of hospitalized patients, 48% of which were considered preventable. Patients with AEs had an average length of stay of 8,5 days longer (range 0 to 70 days) when compared to the average length of stay of patients without AEs. The authors estimated a cost of approximately £2 billion per year, associated exclusively with the increase in hospitalization days of patients who suffered AEs.
The Australian study observed the occurrence of AEs in 7% of hospitalizations, with an average increase of 10 days in the average length of stay. The costs of adverse events corresponded to 16% of direct hospital costs, which represents an increase of 19% in the budget for hospitalizations.
Studies show that harm to patients resulting from health care has a significant impact on hospital spending.
There are reasons to believe that the costs of adverse events in Brazil are underestimated, because the financial information used does not include expenses with hospital employees' salaries, since they are public hospitals, although expenses with outsourced personnel are included. The second aspect concerns the use in the financial analysis of the average amount paid per day of hospitalization. Studies have shown that days of hospitalization after the occurrence of an adverse event are more expensive than those before. Since this discrimination could not be performed in this study, it is assumed that the average value observed is lower than the real average value. (PORTO, 2010)
After analyzing the studies collected, three cases with similar values for the cost of adverse events are proposed.
Below are some examples:
As a scenario for the examples, we propose a 200-bed hospital, where we have 5400 patient-days per month, we can infer that 65000 doses of drugs are administered monthly. We will use this data for the cost calculations with preventable adverse events.
Sentinel events, deaths and legal costs are not included in these calculations.
The values presented represent a minimum estimated cost.
Applying the Didactic Scheme of the Structure of Adverse Events related to Medication Errors we have:
| Hospital with 200 beds – 5400 patients-day/month
· being 540 EA/month; · 270 AEs/month are avoidable; · being 81 EA/month of medication; · being 25 EA/month in the administration stage; · being 12,15 EA/month with moderate or severe damage |
We calculated an average value of 3 days of recovery in the ICU at a cost of R$3.200 per day, according to data from Anvisa.
Cost: 12,15 x 3 days x 3.200 = R$ 116.640 /month.
According to a study by FIOCRUZ/RIO, published in 2010 in the Portuguese Journal of Public Health, by Mendes and collaborators, they presented data similar to the previous case, which, applied to the suggested scenario of a 200-bed hospital, we would have the following data:
| Hospital with 200 beds – 5400 patients-day/month
· being 540 EA/month; · 270 AEs/month are avoidable; · being 135 EA/month with moderate or severe damage; · being 40 EA/month of medication; · being 12 EA/month in the administration stage. |
Again, according to data from Anvisa, we calculated an average value of 3 days of recovery in the ICU at a cost of R$3.200 per day.
Cost of 12 EA x 3 days x 3.200 reais = R$ 115.200 / month
According to another study published more recently in the Journal of the Brazilian Medical Association in 2013, by Mendes and collaborators, the following data were presented: In the sample of 1.103 patients, 65 preventable AEs were identified, out of the 56 patients who suffered preventable AEs, that is, a patient may have suffered more than one preventable AE. These preventable AEs resulted in 373 additional days of hospitalization, 4,6% of which were due to medication errors. Therefore, below is a projection of preventable costs, applying these data to the 200-bed hospital, as suggested in the study. We also included the data of 30% AEs related to medication errors related to drug administration, as exemplified in previous studies:
5.400 patient-days/month x 373 recovery days/1103 patients x 4,6% correspond to medication x 30% correspond to administration = 25 days/month.
25 days x 3.200 reais = R$ 80.000 / month.
According to the cases presented above, we can conclude that in all models the cost values are similar to each other. Remember that we are based on avoidable AEs.
3. CONCLUSION
This study first showed that in several countries there are studies showing concern about mitigating AEs that occur in their institutions. It is worth noting that in the US this issue has been on the agenda for several decades and therefore risk monitoring and management measures are more mature in that market.
It also demonstrates a change in perception regarding the impact that adverse events can cause. It highlights the need to more carefully assess the consequences of these adverse events, such as medication errors, for the patient, family and institution. Unfortunately, adverse events, more specifically errors related to medication administration, occur much more frequently than they should, as shown by national and international studies on the subject, often resulting in longer hospital stays for patients.
Another aspect to be considered is the fact that the financial importance used to treat adverse events with moderate, serious damage or even death could be invested in other areas, such as new technologies, new buildings, human resources, media, among others.
Therefore, it is important and urgent to study this subject, its discussions and especially new proposals to mitigate the risk of new AEs occurring.
16/05/2014
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