©

Many nurses have poor mathematical skills

They do not know where to put the decimal point

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Patients might get10 times more

©

Patients might get10 times more

or 10 times less

©

Patients might get10 times more

or 10 times less

medication than they should

©

If you’re lucky!

©

In 1999 between

45,000 and 98,000

Americans died due to medical errors

many due to

the calculation mistake

©

……the nurse made

The calculation mistake.'‘

BayCare Health System Florida (2008).

©

©

……the nurse made

The calculation mistake.''

"It was the calculation mistake”…

©

The statistics in the 1999 Institute of Medicine report were startling. The report stated that between 45,000 and 98,000 Americans die each year as the result of medical errors.

http://www.surgeryencyclopedia.com/La-Pa/Medical-Errors.html#ixzz0R6k7vjTh

©

We know that it was the human error,'' said the spokeswoman for the hospital, part of the BayCare Health System.

©

Some 7,000 U.S. hospital patients die each year and more than 750,000 are injured as a result of medication mistakes.

These errors have many causes

©

Medical errors

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Easy Flowcharts - for Compliance and Training. See Examples. Free Trial! - www.SmartDraw.comIntroduction and definitions The subject of medical errors is not a new one. However, it did not come to widespread attention in the United States until the 1990s, when government-sponsored research about the problem was undertaken by two physicians, Lucian Leape and David Bates. In 1999, a report compiled by the Committee on Quality of Health Care in America and published by the Institute of Medicine (IOM) made headlines with its findings. As a result of the IOM report, President Clinton asked the Quality Interagency Coordination Task Force (QuIC) to analyze the problem of medical errors and patient safety, and make recommendations for improvement. The Report to the President on Medical Errors was published in February 2000. It is important to understand the terms used by the government and health-care professionals in describing medical errors in order to distinguish between injury or death resulting from mistakes made by people on the one hand, and unfortunate results of treatment on the other. Some allergic reactions to medications or failures to respond to cancer treatment, for example, result from physical differences among patients or the known side effects of certain treatments, and not from prescribing the wrong drug or therapy for the patient's condition. This type of negative outcome is called an adverse event in official documents. Adverse events can be defined as undesirable and unintentional, though not necessarily unexpected, results of medical treatment. An example of an adverse event is discomfort in an artificial joint that continues after the expected recovery period, or a chronic headache following a spinal tap. A medical error, on the other hand, is an adverse event that could be prevented given the current state of medical knowledge. The QuIC task force expanded the IOM's working definition of a medical error to cover as many types of errors as possible. Their definition of a medical error is as follows: "The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems." A useful, brief definition of a medical error is that it is a preventable adverse event. Statistics The statistics contained in the IOM report were startling. The authors of the report stated that between 45,000 and 98,000 Americans die each year as the result of medical errors. If the lower figure is used as an estimate, deaths in hospitals resulting from medical errors are the eighth leading cause of mortality in the United States, surpassing deaths attributable to motor vehicle accidents (43,458), breast cancer (42,297), and AIDS (16,516). Moreover, these figures refer only to hospitalized patients; they do not include people treated in outpatient clinics, ambulatory surgery centers , doctors' or dentists' offices, college or military health services, or nursing homes . Medical errors certainly occur outside hospitals; in 1999, the Massachusetts State Board of Registration in Pharmacy estimated that 2.4 million prescriptions are filled incorrectly each year in that state—which is only one of 50 states. In terms of health-care costs, the IOM report estimated that medical errors cost the United States about $37.6 billion each year; about half this sum pays for direct health care. The United States is not unique in having a high rate of medical errors. The United Kingdom, Australia, and Sweden are presently undertaking studies of their respective health care systems. British experts estimate that 40,000 patients die each year in the United Kingdom as the result of medical errors. Australia has been testing a new system for reporting errors since 1995. Description There is no single universally accepted method of classifying medical errors in order to describe them more fully. The 2000 QuIC report lists five different classification schemes that have been used: type of health care given (medication, surgery, diagnostic imaging, etc.) severity of the injury (minor discomfort, serious injury, death, etc.) legal definitions (negligence, malpractice, etc.) setting (hospital, emergency room, intensive care unit , nursing home, etc.) persons involved (physician, nurse, pharmacist, patient, etc.) The importance of these different ways to classify medical errors is their indication that different types of errors require different approaches to prevention and problem solving. For example, medication errors are often related to such communication problems as misspelled words or illegible handwriting, whereas surgical errors are often related to unclear or misinterpreted diagnostic images. Causes of medical errors The causes of medical errors are complex and not yet completely understood. Some causes that have been identified include the following: Communication errors. One widely publicized case from 1994 involved the death of a Boston newspaper columnist from an overdose of chemotherapy for breast cancer due to misinterpretation of the doctor's prescription; the patient was given four times the correct daily dose, when the doctor intended the dosage to be administered instead over a four-day period. Other cases involve medication mix-ups due to drugs with very similar names. The Food and Drug Administration (FDA) has identified no fewer than 600 pairs of look-alike or sound-alike drug names since 1992. The increasing specialization and fragmentation of health care. The more people involved in a patient's treatment, the greater the possibility that important information will be missing along the chain. Human errors resulting from overwork and burnout. For some years, hospital interns, residents, and nurses have attributed many of the errors made in patient care to the long hours they are expected to work, many times with inadequate sleep. With the coming of managed care, many hospitals have cut the size of their nursing staff and require those that remain to work mandatory overtime shifts. A study published in the Journal of the American Medical Association in October 2002 found a clear correlation between higher-than-average rates of patient mortality and higher-than-average ratios of patients to nurses. Manufacturing errors. Instances have been reported of blood products being mislabeled during the production process, resulting in patients being given transfusions of an incompatible blood type. Equipment failure. A typical example of equipment failure might be intravenous pump with a malfunctioning valve, which would allow too much of the patient's medication to be delivered over too short a time period. Diagnostic errors. A misdiagnosed illness can lead the doctor to prescribe an inappropriate type of treatment. Errors in interpreting diagnostic imaging have resulted in surgeons operating on the wrong side of the patient's body. Another common form of diagnostic error is failure to act on abnormal test results. Poorly designed buildings and facilities. Hallways that end in sharp right angles, for example, increase the likelihood of falls or collisions between people on foot and patients being wheeled to an operating room. Ways of thinking about medical errors One subject that has been emphasized in recent reports on medical errors is the need to move away from a search for individual culprits to blame for medical errors. This judgmental approach has sometimes been called the "name, shame, and blame game." It is characterized by the belief that medical errors result from inadequate training or from a few "bad apples" in the system. It is then assumed that medical errors can be reduced or eliminated by identifying the individuals, and firing or disciplining them. The major drawback of this judgmental attitude is that it makes health care workers hesitate to report errors for fear of losing their own jobs or fear of some other form of reprisal. As a result of underreporting, hospital managers and others concerned with patient safety often do not have an accurate picture of the frequency of occurrence of some types of medical errors. Both the IOM report and the QuIC report urge the adoption of a model borrowed from industry that incorporates systems analysis. This model emphasizes making an entire system safer rather than punishing individuals; it assumes that most errors result from problems with procedures and work processes rather than bad or incompetent people; and it analyzes all parts of the system in order to improve them. The industrial model is sometimes referred to as the continuous quality improvement model (CQI). Hospitals that are implementing error-reduction programs based on the CQI model have found that a non-punitive procedure for reporting medical errors has improved morale among the staff as well as significantly reduced the number of medical errors. At Columbia-Presbyterian Hospital, for example, patients as well as staff can report medical errors via the Internet, a telephone hotline, or paper forms. Proposals for improvement Current proposals for reducing the rate of medical errors in the American health care system include the following: Adopt stricter standards of acceptable error rates. One reason that industrial manufacturers have made great strides in product safety and error reduction is their commitment to improving the quality of the work process itself. Standardize medical equipment and build in mechanical safeguards against human error. Anesthesiology is the outstanding example of a medical specialty that has cut its error rate dramatically by asking medical equipment manufacturers to design ventilators with standardized controls and valves to prevent the oxygen content from falling below that of room air. These changes were the result of studies that showed that many medical errors resulted from doctors having to use unfamiliar ventilators and accidentally turning off the oxygen flow to the patient. Improve the working conditions for nurses and other hospital staff. Recommendations in this area include redesigning hospital facilities to improve efficiency and minimize falls and other accidents, as well as reducing the length of nursing shifts. Make use of new technology to improve accuracy in medication dosages and recording patients' vital signs . Innovations in this field include giving nurses and residents handheld computers for recording patient data so that they do not have to rely on human memory for so many details. Another innovation that helped Veterans Administration (VA) hospitals cut the rate of medication errors was the introduction of a handheld wireless bar-coding system. After the system went into operation at the end of 1998, the number of medication errors in VA hospitals dropped by 70%. Develop a nationwide database for error reporting and analysis. At present, there is no unified system for tracking different types of medical errors. An error in liver transplantation in August 2002 that cost the life of a baby led several researchers to recognize that there is still no national registry recording transplant mismatches. As a result, no one knows how many cases occur each year, let alone find ways to improve the present system. Encourage patients to become more active participants in their own health care. This recommendation includes asking more questions and requesting adequate explanations from health care professionals, as well as reporting medical errors. Address the fact that both patients and physicians have emotional as well as knowledge-related needs around the issue of medical errors. A report published in the Journal of the American Medical Association in February 2003 stated that patients clearly want emotional support from their doctors following an error, including an apology. The researchers also found, however, that doctors are as upset when an error occurs and, additionally, are unsure where to turn for emotional support. What patients can do Patients are an important resource in lowering the rate of medical errors. The QuIC task force has put together some fact sheets to help patients improve the safety of their health care. One of these fact sheets, entitled "Five Steps to Safer Health Care," gives the following tips: Do not hesitate to ask questions of your health-care provider, and ask him or her for explanations that you can understand. Keep lists of all medications, including over-thecounter items as well as prescribed drugs. Ask for the results of all tests and procedures, and find out what the results mean for you. Find out what choices are available to you if your doctor recommends hospital care. If your doctor suggests surgery, ask for information about the procedure itself, the reasons for it, and exactly what will happen during the operation. This fact sheet, as well as a longer and more detailed patient fact sheet on medical errors, is available for free download from the Agency for Health Research and Quality (AHRQ) Website or by telephone order from the AHRQ Publications Clearinghouse at (800) 358-9295.

See also Managed care plans ; Patient rights ; Talking to the doctor .

Resources BOOKS Committee on Quality of Health Care in America, Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 2000.

PERIODICALS Aiken, Linda H., et al. "Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction." Journal of the American Medical Association 288 (October 23-30, 2002): 1987–1993. Cottrill, Ken. "Mistaken Identity: Barcoding Recommended to Combat Medical Errors." Traffic World (July 2, 2001). Dougherty, Matthew. "Preventing Errors: New Initiative Aims to Catch Mistakes before They Happen." In Vivo: News from Columbia Health Sciences 1 (February 11, 2002). Dovey, S. M., R. L. Phillips, L. A. Green, and G. E. Fryer. "Types of Medical Errors Commonly Reported by Family Physicians." American Family Physician 67 (February 15, 2003): 697. Friedman, Richard A. "Do Spelling and Penmanship Count? In Medicine, You Bet." New York Times, March 11, 2003. Gallagher, T. H., et al. "Patients' and Physicians' Attitudes Regarding the Disclosure of Medical Errors." Journal of the American Medical Association 289 (February 26, 2003): 1001–1007. Grady, Denise, and Lawrence K. Altman. "Suit Says Transplant Error Was Cause in Baby's Death in August." New York Times, March 12, 2003. Hsia, David C. "Medicare Quality Improvement: Bad Apples or Bad Systems?" Journal of the American Medical Association 289 (January 15, 2003): 354–356. Nordenberg, Tamar. "Make No Mistake: Medical Errors Can Be Deadly Serious." FDA Consumer Magazine (September-October 2000). Pyzdek, Thomas. "Motorola's Six Sigma Program." Quality Digest (December, 1997).

ORGANIZATIONS Agency for Healthcare Research and Quality (AHRQ). 2101 East Jefferson St., Suite 501, Rockville, MD 20852. (301) 594-1364. http://www.ahcpr.gov . Institute of Medicine (IOM). The National Academies. 500 Fifth Street, NW, Washington, DC 20001. http://www.iom.edu . United States Food and Drug Administration (FDA). 5600 Fishers Lane, Rockville, MD 20857-0001. (888) 463-6332. http://www.fda.gov . OTHER Agency for Healthcare Research and Quality (AHRQ) Fact Sheet. Medical Errors: The Scope of the Problem. Publication No. AHRQ 00-PO37. Agency for Healthcare Research and Quality (AHRQ) Patient Fact Sheet. 20 Tips to Help Prevent Medical Errors. Publication No. AHRQ 00-PO38. Burton, Susan. "The Biggest Mistake of Their Lives." New York Times, March 16, 2003. http://www.nytimes.com/2003/03/16/magazine/16MISTAKE.html . Quality Interagency Coordination Task Force (QuIC)) Patient Fact Sheet. Five Steps to Safer Health Care, January 2001 [cited March 17, 2003]. http://www.ahrq.gov/consumer/5steps.htm . Report of the Quality Interagency Coordination Task Force (QuIC) to the President. Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact, 2000.

Rebecca Frey, PhD

Read more: http://www.surgeryencyclopedia.com/La-Pa/Medical-Errors.html#ixzz0R6lyN8Ls

©

The statistics contained in the Institue of Medicine report were startling. The authors of the report stated that between 45,000 and 98,000 Americans die each year as the result of medical errors. If the lower figure is used as an estimate, deaths in hospitals resulting from medical errors are the eighth leading cause of mortality in the United States, surpassing deaths attributable to motor vehicle accidents (43,458), breast cancer (42,297), and AIDS (16,516). Moreover, these figures refer only to hospitalized patients; they do not include people treated in outpatient clinics, ambulatory surgery centers , doctors' or dentists' offices, college or military health services, or nursing homes . Medical errors certainly occur outside hospitals; in 1999, the Massachusetts State Board of Registration in Pharmacy estimated that 2.4 million prescriptions are filled incorrectly each year in that state—which is only one of 50 states.

Read more: http://www.surgeryencyclopedia.com/La-Pa/Medical-Errors.html#ixzz0R6k7vjTh

©

The subject of medical errors is not a new one. However, it did not come to widespread attention in the United States until the 1990s, when government-sponsored research about the problem was undertaken by two physicians, Lucian Leape and David Bates. In 1999, a report compiled by the Committee on Quality of Health Care in America and published by the Institute of Medicine (IOM) made headlines with its findings. As a result of the IOM report, President Clinton asked the Quality Interagency Coordination Task Force (QuIC) to analyze the problem of medical errors and patient safety, and make recommendations for improvement. The Report to the President on Medical Errors was published in February 2000. Read more: http://www.surgeryencyclopedia.com/La-Pa/Medical-Errors.html#ixzz0R6kcQHPd

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Some 7,000 U.S. hospital patients die each year and more than 750,000 are injured as a result of medication mistakes.

These errors have many causes

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Some 7,000 U.S. hospital patients die each year and more than 750,000 are injured as a result of medication mistakes. These errors have many causes, and many potential solutions, according to a Rutgers-Camden nursing scholar who has studied the topic extensively.

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"It's a major problem. What we're seeing is just the tip of the iceberg," says Kathleen Ashton, a clinical associate professor of nursing at Rutgers-Camden, who adds that many more medication errors are never reported, and some aren't even detected

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TAMPA - One person's error killed Elisha Crews Bryant, hospital officials said last week: a miscalculation by a nurse that overdosed the pregnant 18-year-old with a drug meant to slow her labor.

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But the drug that killed Bryant, magnesium sulfate, is a known hazard. At least 52 overdoses have occurred in recent years, including seven cases in which the patient died or remains in a persistent vegetative state, according to a widely cited nursing journal article.

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We know that it was the human error,'' said Lisa Patterson, spokeswoman for the hospital, which is part of BayCare Health System. "It was the calculation mistake. The nurse made the calculation mistake.''

©

this article in the Chicago Tribune, September 10, 2000, Tribune Staff Writer

Michael J. Berens, reports on the appalling changes that are putting patient's lives

in jeopardy. The problems in large part are due to our United States federal

government injecting itself into the formerly private and excellent healthcare

systems. The other victims are the nurses themselves as you will see in this

thorough examination of the issue.

Overwhelmed and inadequately trained nurses kill and injure thousands of

patients every year as as hospitals sacrifice safety for an improved bottom line, a

Tribune investigation has found.

Since 1995, at least 1,720 hospital patients have been accidentally killed and

9,584 others injured from the actions or inaction of registered nurses across the

country, who have seen their daily routine radically altered by cuts in staff and

other belt-tightening in U.S. hospitals.

Registered nurses are the primary sentinels of patient care, providing first

warning and rapid intervention for those too sick to help themselves. But the

majority of hospitals in Chicago and nationally are quietly eliminating or

supplanting the role of their best-trained, highest-paid nurses, creating a harried

work environment that often compromises patient welfare.

The Tribune analyzed 3 million state and federal computer records to create a

database that, for the first time, quantifies the hidden role registered nurses play

in medical errors. Because of incomplete reporting in the medical field, these

numbers only hint at the full scope of the problem.

And because of lax disciplinary oversight in most states, including Illinois, nurses

who make errors or have problems such as a drug addiction rarely receive severe

punishment; sometimes they travel to a new state to practice again.

Lapses in nursing care sometimes have only minor consequences, but many are

fatal:

In Chicago, at Rush-Presbyterian-St. Luke's Medical Center, 2-year old Miguel

Fernandez received a deadly overdose of sedatives from a newly graduated nurse

who was left alone to perform a delicate medical procedure without training.

In Denver, Mary Heidenreich, 78, was killed early last year when a nurse, who

reported being overwhelmed with the care of 15 patients, inadvertently delivered

a fatal dose of drugs into an intravenous line.

At a Wichita, Kansas, hospital where staff shortages left up to 20 critically ill

patients in the hands of one nurse, patient Deedra Tolson, 38, bled to death

unnoticed after a hysterectomy and 61-year-old Shirley Keck's pleas for help went

unanswered until she suffered permanent brain damage.

©

from a newly graduated nurse who was left alone to perform a delicate medical

procedure without training.

In Denver, Mary Heidenreich, 78, was killed early last year when a nurse, who

reported being overwhelmed with the care of 15 patients, inadvertently delivered

a fatal dose of drugs into an intravenous line.

At a Wichita, Kansas, hospital where staff shortages left up to 20 critically ill

patients in the hands of one nurse, patient Deedra Tolson, 38, bled to death

unnoticed after a hysterectomy and 61-year-old Shirley Keck's pleas for help went

unanswered until she suffered permanent brain damage.

Registered nurses-who receive more education and perform more complicated

procedures than licensed practical nurses or nurse aids-outnumber doctors 2-1 in

hospitals.

State and national disciplinary records indicate, and researches agree, that

registered nurses long have been responsible for more patient deaths and injuries

each year than any other health-care professional-largely because they have more

contact with patients. But the errors have intensified in recent years as working

conditions have put more pressure on nurses.

Although most nurses perform their jobs with distinction, they increasingly find

themselves both victims of hospital mismanagement and perpetrators of medical

errors, forced to walk a thin line between do no harm and doing the impossible.

"Do you know how afraid I was that I was going to fry somebody?" said Marge

Sampson, 55, a registered nurse who worked two decades at the state's largest

public hospital, the University of Illinois at Chicago Medical Center, before stress

drover her to a medical office job.

"It's so scary to spend eight hours, flying by the seat of your pants and just

praying," she said. "In my day, they taught you never4 to give a drug until you

looked it up and verified the proper doses. But you can't do that. There's no time.

You're just dumped into this. It's so nightmarish I can't even explain."

In a marked departure from the previous assertions, officials with the American

Hospital Association, the trade group for 5,000 hospitals, acknowledge that

patients are being placed at risk due to inadequate staffing and insufficient

training.

The dramatic changes that have rocked nursing in recent years have come as

managed care programs grew in dominance and federal Medicaid reimbursements

dropped-two trends that are squeezing hospital profit margins as never before,

said Rick Wade, senior vice president for communications at the AHA.

But the Tribune found, nursing services have been deliberately cut even in

financially thriving hospitals-the result of staff reductions used to preserve

historic profit levels.

©

Medication Math Errors and the Nursing StudentA shocking number of patients die every year in United States hospitals as the result of medication errors, and many more are harmed. One widely cited estimate (Institute of

Medicine, 2000) places the toll at 44,000 to 98,000 deaths, making death by medication "misadventure" greater than all highway accidents, breast cancer, or AIDS. If this estimate

is in the ballpark, then nurses (and patients) beware: Medication errors are the forth to sixth leading cause of death in America.

How many medication errors are miscalculation errors? No one really knows since by some estimates as little as one in ten errors are reported (Pepper, 2002). Of reported errors one FDA study (Thomas, et. al., 2001) found that 7% were due to "miscalculation of dosage or infusion rate." Combining this estimate with the estimate for total deaths, as many as 3,000

to 6,800 deaths are caused annually by medication math errors. This would mean that in the average hospital one patient dies every year or two because someone makes a

miscalculation, and one or two patients are sub-lethally harmed each month. As future nurses, then, there is a distinct possibility that we will harm, or even cause the death of, a

patient over the course of our career.If we believe the adage "first do no harm" applies to us, then what can we possibly do to minimize miscalculation errors? If we only aim to pass Medication Math with an 80% or

above, are we setting the bar high enough? It might be late some Saturday night, you're the only RN on the floor, the hospital pharmacy is closed, and it's up to you to calculate a

needed dosage. Surely getting the right answer only 80% of the time is not acceptable. Perhaps the problem you need to solve is a little different than any you've seen before or recall seeing in the textbook. How confident will you be that your calculation is correct?The time to build confidence is while we are students. I suggest that as conscientious

students we should aim for 95% or better. We should, then, carefully study, learn from, and thereby avoid repeating what mistakes we do make, so that by the time we are working in the real world we can be confident that, if we are vigilant enough, we can approach 100%

proficiency. Since "to err is human," we will always be at risk of not achieving a goal of 100% proficiency, but we cannot aim for less, and knowing that we are always at risk will

make us extremely careful.Neither effort, desire to avoid error, nor carefulness, however, is enough. We need the right

tools and techniques that will help us avoid miscalculations. I believe that dimensional analysis is the most appropriate tool available to us. It is, by far, the best method of solving

medication math problems with the least chance of making errors. As nurses we're not likely to ever use whatever algebra, trigonometry, calculus, or statistics we may know and (even

better?) we need make no effort to learn these subjects, but we should strive for a deep understanding of, and proficiency in, dimensional analysis (DA).

The good news is that mastery of DA is not at all an unobtainable goal. While few could master a vast subject such as algebra in a lifetime, most students should be able to master DA in a few weeks of focused effort. Mastery would mean the ability to solve any problem

that could crop up, no matter how it is presented, while avoiding pitfalls, and retaining proficiency in the years to come. Needless to say, if I thought that nursing students were

mastering DA, I wouldn't be writing this paper.The bad news, then, is that most nursing students seem to have a weak understanding of DA. Most can follow examples given in the textbook; they can then solve all the practice problems that follow the same general format. If quizzes or tests also follow the textbook

examples, most students succeed brilliantly.That all is not well, however, is apparent went problems do not meet expectations. One

sophomore class stumbled badly on a test apparently for this reason. They could all follow, if imitatively, the examples in the textbook, and could therefore do all the practice problems, but when the test presented problems in an unexpected format, most failed--only 2 students passed the test. In their final semester before graduating as RNs, a third failed another test.

This suggests a weak understanding of DA.

©

If we believe the adage "first do no harm" applies to us, then what can we possibly do to minimize miscalculation errors? If we only aim to pass Medication Math with an 80% or

above, are we setting the bar high enough? It might be late some Saturday night, you're the only RN on the floor, the hospital pharmacy is closed, and it's up to you to calculate a

needed dosage. Surely getting the right answer only 80% of the time is not acceptable. Perhaps the problem you need to solve is a little different than any you've seen before or recall seeing in the textbook. How confident will you be that your calculation is correct?The time to build confidence is while we are students. I suggest that as conscientious

students we should aim for 95% or better. We should, then, carefully study, learn from, and thereby avoid repeating what mistakes we do make, so that by the time we are working in the real world we can be confident that, if we are vigilant enough, we can approach 100%

proficiency. Since "to err is human," we will always be at risk of not achieving a goal of 100% proficiency, but we cannot aim for less, and knowing that we are always at risk will

make us extremely careful.Neither effort, desire to avoid error, nor carefulness, however, is enough. We need the right

tools and techniques that will help us avoid miscalculations. I believe that dimensional analysis is the most appropriate tool available to us. It is, by far, the best method of solving

medication math problems with the least chance of making errors. As nurses we're not likely to ever use whatever algebra, trigonometry, calculus, or statistics we may know and (even

better?) we need make no effort to learn these subjects, but we should strive for a deep understanding of, and proficiency in, dimensional analysis (DA).

The good news is that mastery of DA is not at all an unobtainable goal. While few could master a vast subject such as algebra in a lifetime, most students should be able to master DA in a few weeks of focused effort. Mastery would mean the ability to solve any problem

that could crop up, no matter how it is presented, while avoiding pitfalls, and retaining proficiency in the years to come. Needless to say, if I thought that nursing students were

mastering DA, I wouldn't be writing this paper.The bad news, then, is that most nursing students seem to have a weak understanding of DA. Most can follow examples given in the textbook; they can then solve all the practice problems that follow the same general format. If quizzes or tests also follow the textbook

examples, most students succeed brilliantly.That all is not well, however, is apparent went problems do not meet expectations. One

sophomore class stumbled badly on a test apparently for this reason. They could all follow, if imitatively, the examples in the textbook, and could therefore do all the practice problems, but when the test presented problems in an unexpected format, most failed--only 2 students passed the test. In their final semester before graduating as RNs, a third failed another test.

This suggests a weak understanding of DA.

©

This study found that doctors expected a higher level of skill in drug calculation from their peers than they were able to achieve themselves. Furthermore, junior doctors and those working in non-critical care areas scored lower on a drug-dose calculation test. Both these groups reported that their previous education in drug calculations was less than adequate when compared with more senior doctors and those working in critical care areas.Doctors’ self-predicted and actual scores were similar, suggesting they have good insight into their own skill and limitations. However, the mean score judged as adequate was significantly higher than the mean score the doctors achieved themselves: 80% of participants expected a colleague to score 90% or more to practise adequately in a clinical environment. These high expectations, and the group’s failure to achieve them, raise medicolegal concerns about the criteria doctors use to judge their peers. In a US study, 83% of 175 respondents believed prescribing errors were unacceptable and should not occur.15A UK study found that doctors generally had a poor level of skill in calculating drug doses.5,8 We found similarly that junior and newly graduated doctors perform most poorly, and that critical care doctors perform best. Within the critical care specialties, we surveyed a relatively large number of senior anaesthetists, partly explaining the higher scores in this group.Strikingly, participants who stated they had “never” or “unlikely” ever made a mistake in a drug-dose calculation scored significantly lower (62.7%) in the calculation test than those who admitted to past errors (90.6%). This result may be accounted for by the more experienced doctors, who performed better but had longer careers in which to make a mistake. However, it also raises concern that some doctors may lack insight into their ability and overestimate their skill, thus being unaware of their current or past mistakes.

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Reassuringly, most doctors in our study (89%) said they “mostly” or “always” double-check their own drug-dose calculations. This is a higher proportion than in a US study,15 which showed that only half of interns always double-checked their calculated doses. It is difficult to know whether our results truly reflect better workplace practices in Australia, as it has been shown repeatedly that self-reported compliance with desired behaviour is higher than objectively measured compliance.15,16 However, doctors who performed worst in the calculation test were most likely to have a second staff member check their calculated doses. This reflects awareness of their deficiencies and supports the belief that the self-reporting of workplace habits was accurate.Our study also supports previous arguments for standardised drug labelling.5,6,17 Nearly all doctors preferred solutions to be expressed in mg/mL. This preference was supported by significantly higher scores for calculations involving concentrations expressed as mg/mL. Concentrations expressed as percentages or ratios resulted in more calculation errors, potentially leading to adverse events.5,6,18,19Standardising the units for drug concentrations in solution to mass per unit volume would lessen the risk of error by reducing the complexity of dose calculation, particularly in time-critical, high-stress areas.8 These strategies for risk reduction have been effective in the aviation and nuclear industries2,5 and are well suited but underutilised in acute care medicine.

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Some may argue that a written test is a poor predictor of the true performance of doctors in clinical practice. However, residents who show poor calculation skills in a written examination are likely to perform even more poorly under stressful conditions.18It is of concern that over three-quarters of participants (79%) reported never being tested in the skill of drug-dose calculation during their careers, suggesting this skill is assumed. One doctor calculated a dose that was 1000 times the correct dose (Question 7, Box 2). Doctors need to be trained to identify “alarms” that a dose calculation is incorrect or dangerous.20 Directly achievable recommendations to reduce errors include encouraging safe workplace practices such as double-checking one’s own calculations, cross-checking with another staff member, and utilising web-based medication programs.Our study had a number of limitations. The newly constructed questionnaire was not validated, although it was derived from previously used and validated surveys. We cannot exclude the possibility of selection bias, but the response rate was high (74%), from a large representative sample of the hospital’s medical staff, and few data were missing. Although some potential participants may have declined to participate if they expected to perform poorly, this would have biased towards higher actual scores, which is alarming given the generally poor scores achieved. Lastly, it was beyond the scope of this study to assess whether incorrect calculations would have led to clinical errors and affected patient outcomes.

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This study showed that the doctors surveyed expected a higher level of skill in calculating drug doses from their colleagues than they achieved or expected of themselves. In addition, junior doctors and those in non-critical care specialties performed more poorly, clearly confirming the need for improved teaching of drug-dose calculations to medical students and junior staff.21,22To address calculation, mathematical process and arithmetic errors, we recommend ongoing training and enforcement via formal, regular assessment of skill in calculating drug doses for all doctors.7,8,15,17,23,24 In this way, the skill levels of individual doctors may be more likely to reflect the high expectations they have of their colleagues. Since the completion of this study, we have been approached by the hospital’s medical education office to run formal training sessions on this skill for intern staff. This will enable us to conduct further, more robust, research.2,25