| Mistakes are not something that we usually | | | | 21% reported performing wrong-site surgery at |
| associate with the medical field. But medical | | | | least once. One in 27,686 procedures was |
| mistakes do happen mainly because medical | | | | performed in the wrong site. The three most |
| professionals are only humans who can err. In | | | | common locations of wrong-site surgery were |
| medical terms, they are called iatrogenic events, | | | | the fingers, hands, and wrists. 9% of patients |
| defined as unintended harm or suffering caused | | | | suffered from permanent disability. |
| by health care. Medical mistakes are usually | | | | Medical errors go hand in hand with overcrowding, |
| something that people associate with health care | | | | overworked staff and cost cutting. |
| in developing and low-income countries where | | | | (1) Overcrowding. Many hospitals, especially in |
| they lack the right infrastructure and trained | | | | large urban areas, are overcrowded and we are |
| personnel. The fact is, a lot of medical mix ups | | | | not even talking about the flu season, nevermind |
| and mistakes in hospitals and clinics occur all over | | | | H1N1 or another pandemic. There are more |
| the world, including Europe and North America. | | | | patients than the hospital staff and hospital |
| One gets to wonder how many medical | | | | resources can handle. Because of overcrowding |
| misadventures go unreported! | | | | health professionals cannot spend enough time |
| Medical misadventures are classified as Adverse | | | | with patients. Researchers at the Massachusetts |
| Drug Events, Hospital Acquired Infections and | | | | General Hospital (MGH) and Brigham and Woman's |
| Surgical Mistakes. | | | | Hospital (BWH) report that hospitals with high |
| (1) Adverse Drug Events (ADEs) or medication | | | | occupancy rates have increased workloads and |
| mix ups are perhaps the most common. One of | | | | higher patient-to-nurse ratios which are associated |
| the most well-publicized medication mix ups was | | | | with increased incidence of adverse events. |
| the case of Quaid twins who received the wrong | | | | (2) Overworked staff. Several studies have linked |
| dose of heparin. The newborn babies were | | | | medical errors to long working hours and burnout |
| reportedly given an excessive dose which was up | | | | especially among interns and residents. In |
| to 1,000 times the normally prescribed dose. | | | | December 2008, the Institute of Medicine |
| Fortunately, the error was detected early enough | | | | released a report that proposed revisions to the |
| so that the Quaid twins, plus several other babies, | | | | duty hours and workload of medical residents. |
| could be saved. One must not forget that there | | | | According to Michael M.E. Johns, chancellor, Emory |
| are other adverse events besides drugs, as | | | | University, Atlanta and chairman of the |
| evidenced by the recently highly publicized | | | | committee which prepare the report: "Fatigue, |
| excessive radiation exposure incident in California. | | | | spotty supervision, and excessive workloads all |
| A study in France revealed that in the period | | | | create conditions that can put patients' safety at |
| January and September 2005, 267 cases of | | | | risk and undermine residents' ability to learn. The |
| iatrogenic events happened to 116 newborn | | | | report did not recommend the reduction of the |
| babies. 34% were preventable, 29% were | | | | 80-hour working week because it would most |
| severe, 2 cases were fatal, 34 cases were due | | | | likely cost a lot of money and cause understaffing |
| to drugs and 19 cases were identified as medical | | | | in hospitals. However, the proposed changes |
| errors. The study concluded that iatrogenic events | | | | addressed the residents' workload, including the |
| occur frequently and are often serious in | | | | number of hours that residents can work without |
| neonates, especially in infants of low birthweight. | | | | sleep (16 hours), more days off, and restrictions |
| A study in the US revealed that for every 100 | | | | on moonlighting. In another study, researchers at |
| children hospitalized, 11 drug-related mistakes can | | | | the Mayo Clinic reported that distress and fatigue |
| occur. About 500,000 children in the US suffer | | | | among medical residents contribute greatly to |
| from drug mix ups. Less than 4% of medical mix | | | | medical errors. |
| ups are reported. And according to the 1991 | | | | (3) Cost-cutting. The MGH-BWH study reported |
| Harvard Medical Practice Study, there is a 6.5% | | | | that efforts to meet two primary challenges |
| rate of ADEs among adult inpatients, 33% of | | | | facing hospitals today - reducing costs and |
| which were considered preventable. | | | | improving patient safety - may work against each |
| (2) Hospital-Acquired Infections (HAIs). Hospitals | | | | other. The researchers investigated four teaching |
| are not the cleanest of environments and all are | | | | hospitals for 12 months. According to the lead |
| actually the breeding ground for dangerous bugs. | | | | author Dr. Joel Weissman "While financial and |
| All too often, patients get the so-called | | | | political pressures to make health care more |
| Hospital-Acquired Infection (HAI) also known as | | | | efficient are leading to increased hospital |
| nosocomial infection or healthcare-associated | | | | occupancy and greater patient turnover, patients |
| infections. According to the CDC, about 100,000 | | | | and policymakers are quite rightly demanding that |
| people die of HAIs due to antibiotic-resistant | | | | health delivery systems be made safer. Our |
| bacteria. | | | | study suggests that pushing efficiency efforts to |
| In the US, the incidence of HAIs exceeds 2 million | | | | their limits could be a double-edged sword that |
| cases a year and an estimated expenditure of | | | | may jeopardize patient safety." |
| more than $4.5 billion is attributed to HAIs. Most | | | | So what's the health care industry doing to clean |
| are detected 48 hours after admission to the | | | | up its act? In 1999, the Institute of Medicine |
| hospital. In a survey of patients from a pediatric | | | | released the groundbreaking report To Err is |
| ICU between 1992 and 1997, bacterial and fungal | | | | Human: Building a Safer Health System. According |
| infections were reported as follows: Bloodstream | | | | to the report "Beyond their cost in human lives... |
| infections - 28% Ventilator-associated pneumonia | | | | errors...are costly in terms of loss of trust in the |
| - 21% Urinary tract infection (UTI) - 15% Lower | | | | health care system by patients and diminished |
| respiratory infection - 12% Gastrointestinal, skin, | | | | satisfaction by both patients and health |
| soft tissue, and cardiovascular infections - 10% | | | | professionals." |
| Surgical-site infections - 7% Ear, nose, and throat | | | | The good news is that awareness of medical |
| infections - 7%. In fact, a French study on | | | | errors has increased both among health providers |
| newborns reported that the most common | | | | and patients. Hospitals, medical professionals, |
| medical mistakes reported were due to infections | | | | advocacy and watchdog groups are making |
| contracted within the hospitals. | | | | strides in improving the safety of health care. |
| HAIs cannot be fully attributed to mistakes made | | | | The Commission on Accreditation of Healthcare |
| by health professionals but hospital staff are | | | | Organizations (JCAHO) has launched a number of |
| instrumental in preventing them. Risk factors for | | | | initiatives to address patient safety especially |
| HAIs include: | | | | infection control in hospital settings. |
| - Iatrogenic including pathogens on the hands of | | | | The Agency for Healthcare Research and Quality |
| medical personnel, invasive procedures such as | | | | (AHRQ) encourages patients to prevent medical |
| intubation and extended ventilation, indwelling | | | | errors by asking questions. In fact, it has |
| vascular lines and urine catheterization, and | | | | produced several TV spots urging patients to |
| antibiotic use and prophylaxis. | | | | "take charge of their health" and ask questions |
| - Organizational including contaminated | | | | just like they would ask questions about the food |
| air-conditioning systems, contaminated water | | | | they order in a restaurant. The AHRQ |
| systems, and staffing and physical layout of the | | | | recommends the following 10 questions: What is |
| facility. Some places in a hospital are more | | | | the test for? How many times have you done |
| infectious than others. According to a 1986 to | | | | this? When will I get the results? Why do I need |
| 1988 survey by the National Nosocomial Infections | | | | this surgery? Are there any alternatives to |
| Surveillance (NNIS) System of the Centers for | | | | surgery? What are the possible complications? |
| Disease Control and Prevention (CDC), the highest | | | | Which hospital is best for my needs? How do you |
| infection rates occur at the intensive care units, | | | | spell the name of that drug? Are there any side |
| especially the burn ICU, the neonatal ICU, and the | | | | effects? Will this medicine interact with medicines |
| pediatric ICU. Newborn babies, especially those | | | | that I'm already taking? |
| who are premature with low weight weights are | | | | The American Medical Student Association is |
| more susceptible to HAIs. | | | | actively campaigning for safer working conditions |
| - Patient risk factors include the severity of illness, | | | | for medical interns and residents and The |
| underlying immunocompromised state, and length | | | | American Academy of Orthopaedic Surgeons |
| of stay. | | | | launched the Sign Your Site Campaign to prevent |
| (3) Surgical mistakes. And it is not just about | | | | wrong site surgery which includes three actions, a |
| leaving a surgical sponge inside a patient. The | | | | review of the operative procedure with the |
| most frequent surgical mistakes are wrong site | | | | patient and operating room personnel prior to |
| surgeries. In 2001, the Joint Commission | | | | surgery, a review of the patient's chart in the |
| documented 150 cases of wrong site, wrong | | | | operating room prior to surgery, and writing your |
| person or wrong procedure surgery. 76% | | | | initials at the operative site... Sign Your Site! |
| involved surgery on the wrong body part or site; | | | | We we are not safe yet! Medical misadventures |
| 13% involved surgery on the wrong patient and | | | | will continue to occur. The obstacles remain |
| 11% involved the wrong surgical procedure. | | | | formidable what with overcrowding, overworked |
| A 2003 report which surveyed 1,165 hand | | | | staff and cost cutting. In the meantime, patients |
| surgeons was just as startling. 16% reported that | | | | must be vigilant, ask questions and be their own |
| they had prepared to operate on the wrong site | | | | advocate. |
| but then noticed the error prior to the incision and | | | | |