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The Persistence of Medical Error

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Conversation Continues feature ongoing discussions or news on current health topics with links to related materials.'  They are part of the Center for Advancing Health's portfolio of free, evidence-based coverage of what it takes to find good care and make the most of it.'  By Kelly Malcom, Editor, CFAH's Health Behavior News Service.



 

The hospital can be a frightening place, not only because of the injury or illness that bring you there, but also because of common medical errors that can complicate your treatment and recovery. ' While a 1999 Institute of Medicine report opened policy makers' and the public's eyes to the widespread, often life-threatening mistakes made by care providers during the course of treatment, many hospitals still struggle to prevent errors.'  Why?

For starters, a recent article in the New York Times suggests that some doctors and nurses aren't sure what qualifies as an 'adverse event.' ' Medication errors, bedsores, infections, excessive bleeding?'  Thus, only 1 out of 7 such events suffered by Medicare patients are reported. ' Daniel Levinson, inspector general of the U.S. Department of Health and Human Services, says that employees either assumed someone else would report the episode, or they thought it was so common that it did not need to be reported, or they 'suspected that the events were isolated incidents unlikely to recur.''  What's more, when employees did report errors, 'hospitals made few changes to policies or practices.' ' In many cases, hospital executives told federal investigators that the events did not reveal any 'systemic quality problems.'

Systemic or not, medical mistakes happen for a variety of reasons, including simple distraction. For example, the same cell phones that distract many drivers are distracting physicians and nurses at patients' bedsides, even during surgery. ' Could a text message about an upcoming party really have caused this doctor to fail to send an order to stop a medication?'  The challenge, Anne Polta says, is for care providers to balance the potential patient-safety benefits of mobile technology with the desire and tendency to use them for non-clinical purposes.

The U.S. Department of Health and Human Services, hospital leaders and other government officials are working to address some of the more common medical errors, including a goal to decrease preventable hospital-acquired conditions by 40 percent by the end of 2013. ' A good example of these efforts can be found at Hennepin County Medical Center in Minnesota.'  Over the course of nine months, this hospital cut their rate of medication errors from an outrageous 92 percent to nearly zero.

Part of the solution is to enlist the help of patients themselves. Outlined in the Prepared Patient feature article Reducing Your Risk of Medical Errors and echoed in a recent post by blogger and physician Howard Luks, MD, there are simple steps patients can take to reduce their risk of becoming a statistic, including asking for their medical records, writing down questions and seeking second opinions.'  As these examples show, a little bit of awareness can go a long way.



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Conversation Continues feature ongoing discussions or news on current health topics with links to related materials.  They are part of the Center for Advancing Health’s portfolio of free, evidence-based coverage of what it takes to find good care and make the most of it.


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Medical/Hospital Practice   Conversation Continues   Participate in your Treatment   Inside Healthcare  


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