Re: 'It's never just one thing' that leads to serious error

[Guest guest]

I think it's a bit funny - sad funny - when I've gone to medical facilities

across this country. I watch the nurses and doctors put on dainty little laytex

gloves to protect both of us. Well, once they get the gloves on, and they're

protected, they'll touch every damn thing in the room, and on the floor, and

then come over to me. Hello?! Are all you medical folks brain dead?!

Good grief!!

>

> 'It's never just one thing' that leads to serious error

>

> http://www.latimes.com/features/health/la-he-

> errors28jan28,1,185313.story?track=rss

>

> By Brink, Los Angeles Times Staff Writer - January 28, 2008

>

> A technician mistakes an " a " for an " o " in a drug name. A doctor

> misplaces a decimal point in a prescription order. A nurse reaches

> for a vial in a cabinet as she's done hundreds of times before, only

> this time the light is dim and she fails to notice that the powder-

> blue label is more of a sky blue. The slip-ups are often simple, and

> always human, and all have happened in U.S. hospitals.

>

> Each simple mistake is supposed to be countered by a recommended

> backup, a second or third set of eyes -- in other words, guidelines

> to reduce human error. A lot has to be overlooked in the cascade of

> errors that result in serious patient harm.

>

> " It's never just one thing that goes wrong when a serious event

> happens, " says Cohen, president of the Institute for Safe

> Medication Practices, an organization that tracks prescribing errors

> and is sometimes called in to examine a hospital's mistake. " We've

> detailed a situation where we found over 50 mistakes in the system

> before an infant was killed. " The incident, he said, was a 1,000-fold

> overdose of the blood thinner heparin in an Indianapolis neonatal

> intensive care unit that resulted in the deaths of three infants in

> 2006.

>

> Late last year, the infant twins of actor Dennis Quaid and his wife,

> , were the victims of a nearly identical mistake, an overdose

> of heparin at Cedars-Sinai Medical Center. " It was the exact same

> situation in a hospital in Indianapolis that we investigated a year

> earlier, " Cohen says. " The pharmacy dispensed the wrong dose to the

> nursing station. "

>

> The Quaids' newborns, who were being treated for a staph infection,

> have since been released, and the hospital has been cited by state

> regulators for its handling of drugs. Its practice, regulators say,

> had placed pediatric patients in jeopardy.

>

> The mistake calls attention to how far hospitals have to go in

> preventing medical errors and in learning from the mistakes of

> others, even though many have made progress in protecting patients

> within their own institutions. Despite a decade of rising public

> awareness of such mistakes and research into how to prevent them,

> even one of the country's premier institutions and a celebrity couple

> were not immune. Hospitals still have a long way to go to avoid

> mistakenly hurting their charges.

>

> " People used to say that hospital mistakes are kind of like the poor -

> - they're always with you, " says Dr. Lucien Leape, one of the authors

> of a 1999 Institute of Medicine report that estimated 100,000 people

> died each year in the U.S. from preventable hospital errors. " Well,

> no, they don't have to be. "

>

> Hospitals are trying. In a program called the 100,000 Lives Campaign,

> some 3,000 of the nation's 5,000 acute care hospitals, including

> Cedars-Sinai, have voluntarily instituted up to six changes in

> practices aimed at reducing errors. The Joint Commission, a national

> organization that accredits hospitals and other healthcare

> facilities, now requires that patients be informed of " unanticipated

> outcomes. "

>

> But while accountability is improving, hospitals still face

> increasingly complex technology. And medical culture, built on

> individual excellence, not teamwork, is slow to change.

>

> Unfortunately, Cohen says, few hospitals learn from the mistakes, or

> improvements, of others. His organization published the results of

> the Indianapolis incident in a newsletter sent to every hospital in

> the country. If hospitals are to improve, he says, they have to study

> errors that have happened elsewhere.

>

> First instinct: Denial

>

> The mid-1990s saw a rash of medical errors that caught the attention

> of the public, and the medical profession: A Florida man had the

> wrong leg amputated, a New York woman had surgery on the wrong side

> of her brain, and Betsy Lehman, a newspaper reporter whose beat was

> health, died of an accidental chemotherapy overdose at one of the

> nation's top cancer centers, Boston's Dana Farber.

>

> At first, the American Medical Assn. responded with a public

> relations campaign, calling the incidents " isolated " mistakes,

> according to an analysis of the era published in the April 27, 2002,

> British Medical Journal. By 1996, however, the AMA launched a

> National Patient Safety Foundation and changed its stance, admitting

> that such errors were " common. "

>

> But it was the 1999 Institute of Medicine Report that shocked the

> country, and shamed the medical profession into voluntarily adopting

> systems changes. The report estimated that 100,000 patients died

> annually from preventable hospital errors -- about the same as the

> yearly tally of deaths from motor vehicle accidents, breast cancer

> and AIDS combined.

>

> Leape, a leading researcher on medical mistakes, had long said the

> number was a conservative estimate. Sure enough, five years later, a

> review of Medicare records by the Denver-based healthcare ranking

> group HealthGrades found nearly twice as many deaths from preventable

> errors -- up to 195,000 -- in the country's healthcare facilities.

> The higher estimate was never published in a peer-reviewed journal

> and included deaths in settings other than hospitals, such as nursing

> homes.

>

> But since then, hospitals have begun responding to their state's

> reporting laws, and, individually and voluntarily, launching their

> own efforts to improve. One of the most notable is an effort

> sponsored by the Institute for Healthcare Improvement, a nonprofit

> group based in Cambridge, Mass., whose aim is to improve healthcare.

> In that push, called the 100,000 Lives Campaign, 3,000 of the

> nation's 5,000 hospitals volunteered to concentrate on one or more of

> six changes statistically proven to reduce errors. Those changes

> included following evidence-based guidelines to reduce infections and

> improve care for heart attack patients and to assemble teams to

> respond to the earliest signs of a patient crisis.

>

> After a year, the institute reported that the changes made within the

> participating hospitals probably saved more than 120,000 lives, even

> more that what the IOM said was its conservative estimate of

> accidental deaths.

>

> A death related to a medical error can be proven, but a death avoided

> is more difficult to document. In the November 2006 Journal on

> Quality and Patient Safety, the 100,000 Lives Campaign compared the

> volunteer hospitals' actual deaths in one year with statistically

> expected deaths, based on data from the base year 2004. Based on the

> analysis, 122,300 people walked out of hospitals in 2005 unscathed --

> and never knew it might have been otherwise.

>

> Now, all those hospitals and 700 others are signing up for a follow-

> up campaign called the 5 Million Lives Campaign, aimed to halt not

> just deaths, but also injuries and near misses.

>

> Even simple changes can make a difference. One statewide hospital

> group in Michigan followed a plan devised by Dr. Pronovost, a

> critical-care specialist at s Hopkins Hospital, that involved a

> simple checklist, fashioned after the kind of safety list pilots are

> required to check on each takeoff and landing. A landmark study in

> the Dec. 28, 2006, New England Journal of Medicine of 108 ICUs in

> Michigan hospitals found that by using the checklist unfailingly,

> common infections from medical tubing could be reduced by two-thirds.

> Wash hands with soap. Check. Clean patient's skin with antiseptic.

> Check. Wear sterile mask, gown, glove. Check. Put sterile drapes over

> entire patient. Check.

>