Reduction of medical error by introduction of a new clinical management protocol in a poison center

In a previous retrospective study of poison center medical error, a majority of the errors were felt to be "definitely" or "probably" preventable. This prospective study was designed to evaluate the error-reduction effect of the introduction of a new, Intentional Exposure Management Protocol at a poison center. Following a retrospective review of medical error at a poison center, error types and causations were analyzed. A new protocol was introduced requiring the recommendation of an acetaminophen (APAP) serum concentration, documentation of APAP serum concentration results, and follow-up in a clinically relevant time frame, in all cases of intentional exposures. Randomly-selected cases of intentional exposures were then independently reviewed by two Certified Specialists in Poison Information (CSPI) and subsequently by a single medical reviewer. 205 cases from the period of the retrospective review, and 206 cases following introduction of the new protocol were reviewed. Results were analyzed by 2-tailed Fisher's Exact test. The medical reviewer confirmed 71% and 29% of CSPI-identified possible error cases, pre- and post-protocol introduction, respectively. In intentional exposures, failure to recommend an APAP serum concentration, failure to document an APAP serum concentration, and failure to follow-up in a clinically-relevant time frame, all decreased significantly following introduction of the new protocol. Analysis of error types and causations, and relatively simple and practical management protocol changes, can reduce medical error in a poison center setting. This work was supported by DHHS/HRSA/MCHB Grant #4 H4B MC02322-01-01.