Andrea Righi de Oliveira Kelian
Nurse Specialist in Nursing Management, Hospital Management and Health Quality Management.
Among the adverse events (AEs) discussed, one of the most who brings concern are related to medication errors, and more specifically those related to drug administration. The study aims to raise scientific data to propose a model to calculate the cost of Adverses Events in Brazil. A literature research of articles published between 1995-2014, national and international was held. Based on the articles we propose a model with minimum of estimated cost with AE related to management errors. We understand the importance of investing in stocks so you can mitigate the risk of EA instead of having a high cost to treat them.
Key words: patient safety, adverse events, medication errors, medication system.
Currently the subject of medication error is bringing very serious disorders and expressing concerns as to the responsibility to provide a safe environment with quality in nursing care.
The administration of drugs is one of the most serious activities and greater responsibility of nursing and for its implementation is necessary to apply various scientific principles that underlie the action of nurses to provide patient safety.
Medicate patients depends only of human actions and mistakes are part of this nature, however, a well-structured system of medication should promote conditions that help in minimizing and preventing errors, implement standards, rules, actions, proceedings to assist professionals involved.
Adverse events related to medications can lead to major health problems of patients, with significant economic and social repercussions.
The use of medicaments is one of the interventions most frequently used in the hospital environment; however, studies over the past few years have shown the presence of errors in medicaments treatment causing harm to patients ranging from the non-receipt of necessary drug till injuries and deaths (LEAPE et al. 1995; TÁXIS & BARBER, 2003). The administration of medication matches the last opportunity to prevent an error in medication that may have arisen into the prescription or dispensing of medicines.
The health professionals should be aware of and alert to this fact and seek permanently, error prevention measures through new knowledge, behaviors or strategies to protect all involved, especially the patient.
Get a comprehensive view of the medication system view enables professional conditions analysis and interventions to ensure a responsible and safe care to patients and himself.
The medication errors are considered adverse events to drug liable of prevention and may or may not cause harm to the patient, with the possibility to occur in one or several times within the medication process (BATES et al., 1995; LEAPE et al. 1995).
The Institute of Medicine dos EUA published in 1999 a book-report entitled: 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 the publication) higher than in car accidents (43,458 deaths in a year), breast cancer (42,297 deaths in a year) or AIDS (16,516 deaths in a year), placing deaths from errors arising from health care as the 8th leading cause of death in the us.
This publication also brought cost estimation data generated by adverse events over a year in the USA: U$ 17-29 billion per year.
This publication caused a big impact on public opinion in the USA. Then-President Bill Clinton called the federal health agencies to implement the recommendations of the Institute of Medicine.
Data from Brazil, from 2006, about 11,000,000 admissions by SUS (National Health System) and 4,000,000 hospitalizations in the private sector, in an estimated total of 15,000,000 admissions in one year.
According to the data of Brazilian studies, we would have an incidence of 7.6% of patients with adverse events. We would therefore 1,140,000 patients suffering adverse events in Brazil per year.
In March of 2014, the Ministry of Health, the Oswaldo Cruz foundation and ANVISA launched the “reference document for the National Program for Patient Safety,” which also mentions that 10% of patients suffer adverse event and of these 50 % were avoidable. This data refers to a study conducted in several countries such as Australia, England, New Zealand, Canada and others, including Brazil. (DE VRIES, 2008)
The Patient Safety refers to reducing unnecessary damage risks associated with health care (adverse events) to an acceptable minimum. The incidence of patients who suffer adverse reaction when hospitalized can reach almost 17% depending on the study performed.
These adverse events include: increased length of hospital stay, temporary or permanent injuries and even death. It is essential to think about the importance of risk management focused on patient safety.
On the report “To err is human: building a safer health system” of the Institute of Medicine (USA) published in 1999, based on studies conducted in Colorado, Utah and New York, points out that of the 33.6 million admissions made in 1997 in US hospitals, around 44,000 to 98,000 Americans died because of problems caused by medication errors (KOHN et al., 2001).
This way, and based on all the literature research about the subject, we aim to propose a minimum estimated cost model with AE related to management errors.
The results of a study conducted at two tertiary hospitals of large-scale, Brigham and Women’s Hospital and Massachusetts General Hospital in the United States, pointed out an average of 6.5 adverse events to drugs for every 100 admissions, of which 28% could have been prevented (BATES et al., 1995).
Errors in medication can often cause harm to the patient and, according to Bates (1996), about 30% of the damage during hospitalization are associated with medication errors, which also brings serious economic consequences to the health institutions. It is estimated an expenditure of approximately US $ 4,700 per adverse event of medication preventable or about $ 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 around US $ 76.6 billion (BERWICK & LEAPE, 1999; KOHN et al., 2001, ANDERSON, 2002).
Medicating patients requires an effective communication process to be successfully performed. Communication problems can be one of the causes of errors in medication, and originate from various situations encountered in day-to-day professional (BARKER & HELLER, 1964 apud RIBEIRO, 1991, p. 70).
It is known that errors are part of human nature therefore the medication systems should be well structured to promote conditions that help in minimizing and preventing errors, planning processes and implementing standards, rules and actions.
The medication system in the hospital is open and complex, involving several steps are interrelated and interconnected by various actions, developing 20 to 30 different steps during the prescription process, dispensing and administration of drugs, always involving many individuals and multiple transfer requests or materials that 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, which are: selection and obtaining medicine; prescription; preparation and dispensing; medication administration and patient follow-up in relation to the drug effects (NADZAM, 1998).
According to a study made by INCA (National Cancer Institute), in November of 2010, the most common errors in administering medication are inadequate technique, wrong place, inadequate preparation and administration without observing the care for that drug. Errors can result in serious problems for the patient and his family, and generate disabilities, prolong hospital stay and recuperation, exposure to more procedures and measures, delay or inability to resume their social functions and until his death.
The Administration of medicines can be considered in a health institution, as a high-risk activity, they are inherent in daily patient care and practice for this activity is closely linked and dependent on human action.
Nowadays, about 88% of patients seeking for medical care receives drug prescriptions. (CASSIANI, 2005)
In a study conducted in several countries, including Brazil, the 24 hours of 1328 patients in the ICUs were observed in relation to administration of medications and found that the most common errors are:
- Wrong dose;
- Wrong medication;
- Wrong Via;
- Wrong time of administration;
- Administration absence.
In total 1328 patients observed were found between the 24 hours, 861 errors in 441 patients, i.e., the same patient experienced more than one error in these 24 hours. In 12 of them, there was permanent damage or death.
In this analysis, we can see that the total number of observed patients, 33% suffered an error in relation to medication administration.
A study made by University of São Paulo, conducted in 2010, examined five university hospitals and showed that there were 30% errors in medication administration, of these 77.3% at the wrong time, wrong doses in 14.4%, 6.1% wrong via, 1,7% medication delivery unauthorized and 0.5% in exchange for patients. This study analyzed 4958 via intravenous dose administrations and 1500 errors.
Within these studies, the number of adverse events that would be preventable gets close to 60% in the situations described.
If we consider the deaths and the serious injuries that can happen, could avoid much suffering to the patient and their families.
Based on the collected articles we can infer a scheme for greater understanding of the data found:
DIDACTIC SCHEME OF THE RELATED ADVERSE EVENTS STRUCTURE TO MEDICATION ERRORS
Within these surveyed studies, were found few materials related to the cost of non-quality, specifically talking about costs of an adverse event related to medication errors.
Most studies report that expenses with adverse events, bring an estimated cost in general, that is, the cost from any type of adverse event.
In the 50 and 60, there were records of the occurrence of adverse events (AE) in health services, but it was in the 90s that studies have shown the importance of social and economic costs of these events. The Harvard Medical Practice Study (HMPS) estimated that EAs occurred in 3.7% of admissions to acute care hospitals in the state of New York, United States of America (USA) in 1984. (PORTO, 2010).
The methodology used by HMPS formed the basis for other studies in different countries.
Study by Thomas Ej in hospitals in the states of Utah and Colorado, USA, showed that 3% of hospitalizations occurred EAs, which are preventable in 33% (Utah) and 27% (Colorado) cases. They estimated that, with the elimination of preventable AEs, could save between 17 and 29 billion dollars, including the loss of income for inactivity, disability and medical expenses.
Study in the UK estimated that EAs occurred in 10.8% of hospitalized patients, 48% considered preventable. Patients with AEs had an average of 8.5 days more permanent (range 0 to 70 days) compared to the average stay of patients without AEs. The authors estimated a cost of about 2 billion pounds per year, exclusively associated with increased duration of hospitalization of patients who experienced AEs.
An Australian study found the occurrence of adverse events in 7% of hospitalizations, with an average increase of 10 days in the average length of stay. The costs of adverse events accounted for 16% of direct hospital costs, representing an increase of 19% in the budget of admissions.
Studies show that patient harm arising from health care have significant impact on hospital spending.
There are reasons to assume that the costs of adverse events in Brazil are underestimated, that because financial information used does not include the cost of the salaries of medical staff, because they are public hospitals, although spending on outsourced services personnel are computed. The second aspect concerns the employment in the financial analysis of the average amount paid per day of hospitalization. Studies have shown that hospitalization days after the occurrence of EA are more expensive than the previous ones. As such discrimination cannot be performed in this study, it is assumed that the observed average value is smaller than the actual average value. (PORTO, 2010)
After analyzing the collected studies, it is proposed three cases with similar values for the cost of adverse events.
Follows below the examples:
As examples, we propose a 200-bed hospital, where we have 5400 patient-days per month, we can infer that 65,000 doses of drugs are administered monthly. We will use this data for cost calculations preventable adverse events.
Not included in these calculations the sentinel’s events, deaths and judicial costs.
The values shown represent an estimated minimum cost.
1. Applying Didactic scheme of adverse events structure related to medication errors, we have:
|Hospital 200-beds – 5400 pacients-day/month|
· being 540 AE/month;
· being 270 AE/month avoidable;
· being 81 AE/month of medication;
· being 25 AE/month the administration of step;
· being 12,15 AE/month with moderate or severe damage
We estimate an average of three days of recovery in ICU at a cost of R$ 3,200 per day, according to Anvisa data.
Cost: 12,15 x 3 days x 3.200 = R$ 116.640 /month.
2. According to a FIOCRUZ / RIO study, published in 2010 in the Portuguese Journal of Public Health, by Mendes and colleagues brought similar data to the previous case, which applied to the suggested scenario of a 200-bed hospital would have the following data:
|Hospital 200-beds – 5400 pacients-day/month|
· being 540 AE/month;
· being 270 AE/month avoidable;
· being 135 AE/month with moderate or severe damage
· being 40 AE/month of medication;
· being 12 AE/month the administration of step;
Again, according to Anvisa data, we calculated an average of three days of recovery in intensive care at a cost of R$ 3.200 per day.
Custs of 12 AE x 3 days x R$ 3.200 = R$ 115.200 / month
3. According to another study published recently in the Journal of the Brazilian Medical Association in 2013, by Mendes and colleagues presented the following data: In a sample of patients 1103, were identified 65 AE preventable, 56 patients who suffered preventable adverse events, that is, a patient may have experienced more than one AE avoidable. These preventable AE produced 373 days to more of hospitalization, and 4.6% was for medication errors reason. Therefore, follows below a projection of avoidable costs, applying this data to the 200-bed hospital, as suggested in the study. We also include the data of 30% AE regarding medication errors related to medication administration, as exemplified in previous studies:
5.400 pacients-day/month x 373 days of recovery/1103 pacients x 4,6% correspond to medication x 30% correspond to administration = 25 days / month.
25 days x R$ 3.200 = R$ 80.000 / month
According to the cases presented above we can conclude that in all the models, the values of the costs are like each other. Remembering that we are based in avoidable AE.
This first study showed that in many countries there are studies showing the concern to mitigate AE that occur in their institutions. It is noteworthy that in the US, this issue is on the agenda for decades and, therefore, monitoring and risk management measures are more mature in that market.
It also shows the change in perception of the shock that the AE can cause.
Brings out the need to assess with more carefully the consequences for the patient, the family and the institution of these AE, for example, a medication error. Unfortunately, the adverse event, specifically the error related to medication administration, occurs much more often than it should, as shown by the national and international studies on the subject, often causing long periods of hospitalization to the patient.
Another aspect to be considered is since the financial importance used to treat adverse events with moderate damage, severe or even death could be invested in other areas such as new technologies, new buildings, human resources, media, and others.
So, it is important and urgent the study on this subject, their discussions and especially new proposals to mitigate the risks of new happen Adverse Events.
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