SAN FRANCISCO — Using a simple system of reading back medical orders reduced the error rate from 9.1% to zero in an inpatient pediatric unit, according to a poster presentation at the annual meeting of the Pediatric Academic Societies.
“Although this was a small study, these results are very encouraging,” Dr. Michael Vossmeyer of Cincinnati Children's Hospital Medical Center said in a statement.
At Cincinnati Children's Hospital, rounds are conducted inside patients' rooms. The attending physician or chief resident communicates the order orally, and the resident physician enters it into the computer system.
For the study, baseline data were gathered on 5 consecutive days. Each day, all orders entered during rounds were audited after rounds by an attending physician without the knowledge of the residents. Of 77 consecutive orders, 7 were found to contain errors. Most of the errors were in dosages that would not have affected patient safety, but in two instances, the resident wrote down the wrong drug.
Then Dr. Vossmeyer instituted the new process. Before leaving the patient's room, the resident would read back the orders to the attending physician, and the attending would sign the orders only if they were correct. The procedure added less than 90 seconds to each patient visit, and it was well accepted by the staff. Once again, data were collected on 5 consecutive days without the knowledge of the residents. Of 75 orders, there was not a single error.
“We're doing a follow-up study to determine if the results are sustainable and the process is reliable, but they appear to be very generalizable,” Dr. Vossmeyer said in the statement. “That's particularly important for tertiary patients, such as children with organ transplants, where proper doses mean so much.”
The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.