Monthly Newsletter

May 2025 Monthly Newsletter

In This Issue -

Key Aspects of Quality and Patient Safety
Terminology Related to Medication Errors
Adverse Drug Events at Alarming Rate

Digital Transformation of Medicine
Free Live Risk Mgmt Webinars May 6th, May 20^th
Auditing to Quality Compliance Standards – Workshop in Nashville

Key Aspects of Quality and Patient Safety

Avoiding Patient Harm

Healthcare must be safe, meaning preventing harm to patients and avoiding exposure to preventable risks. Quality standards and patient safety are interconnected and crucial for providing effective and safe healthcare. Patient safety is a cornerstone of high-quality care, encompassing practices that prevent harm and ensure safe outcomes. Quality standards aim to ensure that healthcare services are delivered in a way that is safe, effective, timely, efficient, equitable, and patient-centered.

Reimbursement is now contingent upon providing safe, quality care. Due to the shift towards Value-Based Care (VBC), reimbursement for services is becoming increasingly contingent on the provider's ability to demonstrate safe, quality care. This means that providers are not just paid for the quantity of services they provide, but also for the quality and outcomes achieved.

VBC programs, also referred to as alternative payment models, often utilize specific quality measures to assess and reward providers for achieving desired outcomes. These measures can include patient safety indicators, patient experience scores, and clinical quality metrics. These payment arrangements often hold physicians accountable in some way for their patients’ quality of care and utilization of services through use of performance measures and financial risk requirements.

Medication errors rank as the most frequent and avoidable source of patient harm.

Errors can manifest at various points in the healthcare process, ranging from prescribing to actual drug administration. Given the gravity of this issue, regulatory bodies have introduced guidelines to reduce the occurrence of these incidents. Our next topic is information to better understand the difference between an ADR, ADE, medication misadventure and a Sentinel Event.

Terminology Related to Medication Errors

To comprehensively assess the true impact of medication errors in the healthcare industry, one must become familiar with the nomenclature used to describe events associated with medication errors. The following is an overview of the typical terminology used in medical literature to describe events associated with medication errors.

Adverse Drug Reaction (ADR)

As defined by the World Health Organization, an ADR is a harmful, unintended reaction to a medication occurring at normal treatment doses. Adverse drug reactions (ADRs) remain a challenge in modern healthcare, particularly given the increasing complexity of therapeutics, an ageing population and rising multimorbidity.

Adverse Drug Event (ADE)

An adverse drug event is a broader term encompassing any harm resulting from medication, including harm from the drug at a standard dose and harm due to inappropriate dosage or overdose. It refers to an injury resulting from medical intervention related to a drug including harm caused by drugs or from the usage of drugs. Extracting ADEs from clinical records can help physicians associate adverse events to targeted drugs.

An ADE is considered to be more comprehensive and clinically significant than adverse drug reaction (ADR), which also cause excess length of stay, extra costs, and mortality of patients.

Medication Misadventure

A medication misadventure is any iatrogenic incident or hazard associated with medication. Medication misadventures include medication errors, adverse drug reactions, and adverse drug events. Older adults, particularly those late in life, are at higher risk for medication misadventure, yet bear the burden of increasing polypharmacy. It is incumbent on practitioners who care for this vulnerable population to use one or more approaches to deprescribe medications that impose a greater burden than benefit, including medically futile medications. It is essential that health care providers use compassionate communication skills when explaining these interventions with patients and families, pointing out that this is a positive, patient-centric intervention.

Sentinel Event

The Joint Commission defines a sentinel event as "an unexpected occurrence involving death, serious physical or psychological injury, or the risk thereof." Serious injury means the loss of a limb or function and encompasses any process variation where a recurrence would carry a significant chance of a serious adverse outcome.

Sentinel events may involve medication errors, adverse drug events, and medication misadventures. Importantly, sentinel events are not limited to medication-related errors but can result from any clinical care process mistake, including surgical, diagnostic, and treatment errors. The Joint Commission encourages reporting of sentinel events, but it is not mandatory, and the organization provides support and expertise during the review of these events.

When Medication Errors Commonly Occur

The following steps outline potential places where medication errors may occur:

Ordering and prescribing
Documenting
Transcribing
Dispensing
Administering
Monitoring

Root cause analysis (RCA) is one of the most widely used approaches to improving patient safety, but its effectiveness has been called into question. Studies have shown that RCAs often fail to result in the implementation of sustainable systems-level solutions. According to the Agency for Healthcare Research and Quality, there are eight common root causes of medical errors which include:

Communication Problems - Communication breakdowns are the most common causes of medical errors. Whether verbal or written, these issues can arise in a medical practice or a healthcare system and can occur between a physician, nurse, healthcare team member, or patient. Poor communication often results in medical errors.
Inadequate Information Flow - Information flow is critical in any healthcare setting, especially within different service areas. Insufficient information flow happens when necessary information does not follow the patient when they are transferred to another facility or discharged from one component or organization to another. Inadequate information flow can cause the following problems:
- The lack of crucial information when needed to influence prescribing decisions.
- Lack of appropriate communication of test results.
- Poor coordination of medication orders for transfer of care.
Human Problems - Human problems occur when standards of care, policies, processes, or procedures are not followed properly or efficiently. Some examples include poor documentation and labeling of specimens. Knowledge-based errors also occur when individuals do not have adequate knowledge to provide the care that is required at the time it is needed.
Patient-Related Issues - These may include inappropriate patient identification, inadequate patient assessment, failure to obtain consent, and insufficient patient education.
Organizational Transfer of Knowledge - These issues can include insufficiencies in training and inconsistent or inadequate education for those providing care. Transfer of knowledge is critical in most areas specifically where new employees or temporary help is used.
Staffing Patterns and Workflow - Inadequate staffing alone does not lead to medical errors but can put healthcare workers in situations where they are more likely to make a mistake.
Technical Failures - Technical failures can include complications or failures with medical devices, implants, grafts, or pieces of equipment.
Inadequate Policies - Often, failures in the process of care can be traced to poor documentation and non-existent, or inadequate procedures.

Adverse Drug Events (ADEs) are at Alarming Rate

Adverse drug events (ADEs) are a significant public health issue, ranking as the fourth leading cause of death in the United States and focus for intervention to ensure improved patient safety. An ADE is any harm caused by a medication, including side effects, medication errors, allergic reactions, and drug interactions. Studies indicate that nearly 50% of ADEs are preventable, particularly those linked to high-risk medications such as anticoagulants, opioids, insulin, and certain cardiovascular drugs.

ADEs account for more than 3.5 million physician office visits and 1 million ED visits annually, according to the National Library of Medicine 2024 article. Each year, in the United States alone, 7,000 to 9,000 people die as a result of a medication error.

Understanding the margin of error that can occur, hopefully, we can reduce ADEs through education and training. It is believed that preventable medication errors impact more than 7 million patients, cost almost $21 billion annually across all care settings, and are found to be under reported.

AHRQ posted an article recently, in December 2024 entitled Medication Errors and Adverse Drug Events stating that an ADE is defined as harm experienced by a patient as a result of exposure to a medication and one of the most common preventable adverse events in all settings of care, mostly because of the widespread use of prescription and nonprescription medications.

A classic study published back in 2011 by AHRQ states that of inpatient medication errors found, approximately 90% occurred at either the ordering or transcribing stage. These errors had a variety of causes, including poor handwriting, ambiguous abbreviations, or simple lack of knowledge on the part of the ordering clinician. The article states that a Computerized Provider Order entry (CPOE) system can prevent errors at the ordering and transcribing stages by (at a minimum) ensuring standardized, legible, and complete orders.

Digital Transformation of Medicine, ADEs and CPOE

ADEs and Computerized Provider Order Entry (CPOE) Systems

While evidence suggests that the digitization of health care is having a positive effect on safety and quality, many challenges and unanticipated consequences have emerged.

CPOE is the process of electronic entry of physician and advanced practice provider (APP) orders for diagnosis and treatment of patients (e.g., prescription medications, lab and imaging tests, referrals, etc.). Delegating order entry to care team members can increase practice efficiency, improve care gap closure, reduce physicians’ administrative burden, and encourage non-physician health care professionals to take on new tasks and operate at the top of their license. However, there is great responsibility to entering orders even into a digitalized CPOE system.

A sophisticated CPOE system offers numerous advantages over traditional paper-based order-writing systems. Examples of these advantages include: averting problems with handwriting, similar drug names, drug interactions, and specification errors; integration with electronic medical records, clinical decision support systems, and adverse drug event reporting systems; faster transmission to the laboratory, pharmacy, or radiology department; ability to recommend alternative tests or treatments that may be safer or lower cost; and potential economic savings.

CPOE systems are generally integrated with another system, such as the Electronic Health Record system or some form of clinical decision support system (CDSS), which can help prevent errors at the medication ordering and dispensing stages and can improve safety of other types of orders as well.

A typical CDSS suggests default values for drug doses, routes of administration, and frequency and may offer more sophisticated drug safety features, such as checking for drug allergies or drug–drug or even drug–laboratory (e.g., warning a clinician before ordering a nephrotoxic medication in a patient with elevated creatinine) interactions. The most sophisticated CDSSs prevent not only errors of commission (e.g., ordering a drug in excessive doses or a drug to which the patient has a known allergy), but also of omission (e.g., failing to order prophylaxis against deep venous thrombosis in a patient who underwent joint replacement surgery). CDSSs are also increasingly being deployed to address overuse—for example, a systematic review of CPOE for radiologic studies found that CDSS can improve adherence to guidelines for diagnostic imaging and reduce overall test usage.

New Safety Concerns: Implementation Issues and Workflow Impact of CPOE

The implementation of CPOE has proven to be a complex process, and early users experienced high-profile failures or safety hazards that in some cases led to abandonment of the system, according to a March 2025 Patient Safety report posted by the Patient Safety Network entitled Computerized Provider Order Entry.

No Longer a Quality Measure – but why?

The Centers for Medicare & Medicaid Services (CMS) has eliminated the previously required CPOE and clinical decision support objectives and associated measures. Similarly, The Joint Commission has eliminated previous prohibitions on documentation assistants entering orders on behalf of physicians. However, the American Institute of Healthcare Compliance (AIHC®), a Licensing/Certification partner with CMS, continues to provide CPOE online training to practices due to provider demand to ensure quality and reduce errors. This stresses the need to provide specialized training of medical assistants entering orders on behalf of the provider.

Medication errors most commonly occur during the prescribing, ordering, and administration stages. Nearly 50% of all medication errors occur when a medication is prescribed or ordered. As stated in the Reducing Medication Errors at Transitions of Care is Everyone’s Business, an article published by the National Library of Medicine, studies reveal that nurses and pharmacists identify 30% to 70% of medication-ordering errors. Medication errors are a pervasive but preventable problem. So, how is your organization addressing this issue?

Free Live Webinars

May 6, 2025 Adapting Risk Management in Value-Based Environment

May 20, 2025 The New DOJ Corporate Whistleblower Awards Pilot Program

Fall Quality Workshop – Nashville, TN

Register during the early bird special and save $250 on registration fee!

Auditing to Quality Compliance Standards – a live 2-day training event.

Speakers are:

Dr. Lilian Alevato MD | CMO-CCO MBA, FABQAURP, CHCQM-PHYS-ADV, CHA, OHCC, FAACM, PCMH-CCE and
Joanne Byron, LPN, BS, CCA, CIFHA, CHA, COCAS, CORCM, CHCO, HPOC, OHCC, CMDP, ICDCT-CM/PCS

Click here to register. Download the Information Packet with Agenda, what you will learn and other information you need to know prior to registering. The American Institute of Healthcare Compliance, a licensing/certification partner with CMS.