Reminds me of another oft-quoted steaming pile of crap - that "To Err Is Human" abomination that has cursed us with 2 1/2 decades of people who earnestly believe that medical errors kill 100K people per year.
I went down a rabbit hole a few years ago trying to figure out how they got that figure. I forget the details now but essentially there’s some data collection software/third party that looks at vitals and lab abnormalities and if certain parameters are satisfied it chalks it up to medication error. I remember that INR being >1.4 if the pt was below that on admission being one, and I remember propofol given and BP being >20% below the previously documented BP being another. The system showed something like 60% of inductions as being a propofol overdose/med error. Then if that pt didn’t survive it was counted as a med error.
Examples: from the IHI GTT (a trigger tool)
M2–Partial Thromboplastin Time (PTT) Greater than 100 Seconds
Elevated PTT measurements occur when patients are on heparin. Look for evidence
of bleeding to determine if an adverse event has occurred. Elevated PTT in itself is not an adverse event—there must be manifestation such as bleeding, drop in Hg or Hct, or bruising.
M3–International Normalized Ratio (INR) Greater than 6
Look for evidence of bleeding to determine if an adverse event has occurred. An elevated INR in itself is not an adverse event.
M11–Over-Sedation/Hypotension
Review the physician progress, nursing, or multidisciplinary notes for evidence of over- sedation and lethargy. Review vital signs records or graphics for episodes of hypotension related to the administration of a sedative, analgesic, or muscle relaxant. Intentional overdose is not considered an adverse event.
S8–Intra-Operative Administration of Epinephrine, Norepinephrine, Naloxone, or Romazicon
These medications are not routinely administered intra-operatively. Review anesthesia and operative notes to determine the reason for administration. Hypotension caused by bleeding or over-sedation are examples of adverse events that might be treated with these medications.
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