All Entries Tagged With: "medical error"
Radiation continues to harm–this time, the victims are preemies
A recent New York Times article has exposed yet another patient safety incident involving radiation, and this time the mistake was on premature infants at State University of New York Downstate Medical Center in Brooklyn, NY.
The incident, which was discovered in July, 2007, is one of several that has prompted the Times to run its “Radiation Boom” series, which explores the increasing use of medical radiation though new and old technologies, including over radiation of cancer and stroke patients, much of which is caused by misuse of equipment.
Over radiation at Downstate Medical Center occurred from too-frequent full body X-rays of premature babies, CT scanners’ radiation levels being set too high, and poorly positioned babies, making it hard to interpret images.
Radiation regulations are sparse. According to the Times, it’s up to states to decide what, if any, standards radiologists and other similar technicians need to meet. In some states, hair dressers might have tougher standards, and many states do not require continuing education for radiology technicians, though equipment is often updated and becoming increasingly more complex.
Are you confident in your hospitals radiation policies? Is it a concern? Post below.
Boston Globe highlights dangers of alarm fatigue
In a two-part series, The Boston Globe has explored the dangers of alarm fatigue, a term used to describe frontline staff becoming desensitized to the incessant beeping of copious amounts of medical machines in hospitals.
Alarms are ignored because they are not high priority, such as those that indicate low batteries; because they are too frequent, such a nuisance alarms that go off when a lead falls off a patient; or too sensitive, sounding off when a patient coughs or turns over. There is also the danger of turning down or shutting off alarms because they keep going off unnecessarily, only to be missed later when there is a true emergency. Alarms can also be programmed incorrectly.
The Globe identified at least 15 deaths in the past six years due to alarm problems, but experts told the Globe that finding a solution to alarm fatigue isn’t easy. Fewer monitors might help, but it’s difficult to convince physicians not to use such readily available technology, even when a patient may not need it. Another option, smart monitors, would monitor multiple patient indicators before going off, lessening the chance of a false alarm.
The problem is certainly at the forefront of patient safety. I recently spoke with experts at the ECRI Institute, which consistently ranks alarm fatigue as a top healthcare technology hazard, about the problem in the latest issue of Patient Safety Monitor Journal. They say the amount of alarms a single nurse must listen for during his or her shift reaches into the hundreds.
What do you think? How can we start to solve alarm fatigue?
Don’t forget to follow-up on those hospital tests
A study published February 8 in the BMJ Quality and Safety journal found that 75% of hospital tests are not followed up, which may lead to serious issues for patients.
Researchers looked at 12 international studies and found that between 20% and 61% of inpatient test results were not followed up after a patient was discharged, as well as between 1% and 75% of emergency care patient tests, reports HealthDay News.
Without follow-up tests, patients can experience missed diagnoses or delayed diagnoses, the study found. The follow-up on tests was least likely for patients moving from inpatient to outpatient care and for patients with critical test results.
How does your facility ensure follow-ups with patients after discharge? Let us know in our comment section.
Physicians recall their shocking stories of what went wrong
The last thing a patient wants to hear is that their doctor made a mistake. An article published in Reader’s Digest gives doctors the spotlight in telling their horrific, sometimes fatal, mistakes made in the hospital.
I thought our readers would find this interesting. Read the stories of real life doctors whose career and lives were put on the line.
Well known patient safety advocates Peter Pronovost, MD, PhD and Robert M. Wachter, MD, among others, tell their stories of simple mistakes with dire consequences. Wachter recalls a mistake he made as a second-year medical student by simply failing to read a textbook chapter. The article is just another reminder that healthcare is slowly but surely becoming more transparent.
Have you ever made a mistake in a healthcare setting? Was it made transparent? Did you or the hospital learn from the mistake? We’d love for you to share below.
Dennis Quaid documentary about preventing harm premieres this weekend
Many readers of this blog likely recall that Dennis Quaid’s newborn twins received an overdose of Heparin in 2007, and almost died because of the adverse event. Quaid has taken the lessons learned from this experience and channeled that into becoming a patient safety advocate. Working with the Texas Medical Institute of Technology, Quaid hosts and narrates a documentary titled “Chasing Zero: Winning the War on Healthcare Harm” (Charles Denham, MD, chairman of TMIT, is also in the documentary). The Quaid Foundation recently joined the TMIT.
For those of you who work in patient safety and quality improvement on a daily basis, the documentary will likely bring up many issues with which you’re already familiar: adverse event rates, building a culture of safety vs a culture of blame and shame, and look-alike/sound-alike medications to name a few. It also leans on well-known advocates and leaders in the field, including Donald Berwick of the Institute for Healthcare Improvement, who was recently nominated to lead the CMS, and Susan Sheridan, co-founder of the group Consumers Advancing Patient Safety (CAPS).
If you’re looking for something deeply touching and eye opening to watch this weekend, the Discovery Channel will be airing the documentary at 8 am on Saturday, April 24. The documentary was supposed to have been premiered this week at the International Forum on Quality and Safety in Healthcare, in Nice, France. However, the volcanic eruption in Iceland prevented many attendees from getting there, including Quaid and Denham.
You can also watch the documentary in a few parts, by clicking here and finding the Discovery Channel’s CME page.
Would you consider showing something like this at your hospital?
New York Times article exposes radiation therapy errors
In a horrifying and emotional account, the New York Times explored the topic of radiation therapy errors in a recent article, one which I would recommend when you have 10 or 15 minutes to sit down and read. Although radiation therapy errors are severely underreported, the New York Times reviewed cases from New York State, which is one of the most progressive states when it comes to reporting this type of error. Between 2001 and 2008, 621 radiotherapy mistakes were reported or recorded, many of which were minor. However, those that were not proved to be deadly and painful for the recipients along the way.
At the heart of the two major errors described in the story is technology failure, combined with human failure. Radiation therapy is delivered to cancer patients via complex technological equipment which in turn must be worked by well-trained medical physicists. If both components (the technology and the staff) are not doing their jobs as they should be, an error can occur. The harrowing accounts of two patients involve repeated error–equipment not functioning correctly and staff not catching the error for many days in a row.
Although the story is about radiation therapy, and not surgery, I couldn’t help but think about the Universal Protocol (UP) throughout reading it. If the surgical team is supposed to do a last minute time out to ensure that the correct patient is about to recieve the correct procedure to the correct area of the body, why are there not similar protocols in place for something like radiation therapy? Perhaps because these errors are less reported, there is less known about how to prevent them? Perhaps there are and this story did not bring them to light? Perhaps there are but (as with the UP sometimes) technologists ignore some steps?
Anyway, be sure to check out the article yourself. As a patient safety professional you may be interested to see it highlight many aspects of an error that can be found in much more minor errors (communication failures, human factors, software malfunction), perhaps something you experience during your more often than extreme radiation errors.
Minnesota reports zero deaths from patient falls in 2009
Minnesota has been collecting data around and publicly reporting adverse events in hospitals for the past six years. However, 2009 was the first year that officials could say that there were no deaths resulting from patient falls, normally one of the most common adverse events, reports the St. Paul Pioneer Press. The state’s Department of Health released yesterday its sixth annual public report called Adverse Health Events in Minnesota. During the previous year there were ten deaths resulting from patient falls. The state launched a campaign called “Safe from Falls” in 2007 that aimed to bring attention to why patient falls were occurring and implementing best practices to prevent them. It’s because of this (which continued running in 2009) and other techniques that individual hospitals employed that the falls rate dropped to 76 reported events, a decline of 20%. Additionally, falls did not become a reportable adverse event in Minnesota until 2007.
Although this milestone is one to be celebrated, state officials told the Pioneer Press that they were not losing sight of the fact that there were still four patient deaths resulting from adverse events, and many other instances of harm. In total, hospitals reported 301 adverse events between October 2008 and October 2009 (the period of time during which data are collected). This number represented a decline of 3.5% from the prior year.
Pressure ulcers remained the top most reported event. Officials said that for the first time they noticed pressure ulcers were a bigger problem for surgical patients, who perhaps have not had all of the precautions for skin breakdown provided. Additionally, the number of wrong-site, -patient, or-procedure surgeries increased, from 39 to 44. This is most likely because hospitals are doing a better job of recording when they occur during minor procedures, reports the Pioneer Press.
Check out the article here. Does your state publish as thorough a report as Minnesota about adverse events? Do you wish you state was as vigilant about collecting this type of data at all?
AHRQ offers ten tips for keeping patients safe
For those hospitals looking for a concise list of actions to take to prevent adverse events and improve patient safety, the Agency for Healthcare Research and Quality (AHRQ) has created just that. The AHRQ has an extensive Web site for those wanting to learn about the prevention of medical errors. This list is one small part of the site, which contains all types of resources such as speeches, toolkits, studies, journal articles, and more.
The ten tips are:
- Prevent central line-associated blood stream infections
- Re-engineer hospital discharges
- Prevent venous thromboembolism
- Educate patients about using blood thinners safely
- Limit shift durations for medical residents and other hospital staff if possible
- Consider working with a Patient Safety Organization
- Use good hospital design principles
- Measure your hospital’s patient safety culture
- Build better teams and rapid response systems
- Insert chest tubes safely
Which of these tips has your hospital focused on in the past year? Which are you hoping to incorporate into your strategy for good patient care in 2010?
Click here to find the tips with full descriptions of why they made the list.
INQRI blog hosts two-week series in observance of “To Err is Human” anniversary
The Interdisciplinary Nursing Quality Research Initiative (INQRI) blog, one of my favorite places to go for nursing and quality improvement news, is hosting a two-week series of blog posts in honor of the 10 year anniversary of the “To Err is Human” report. As mentioned in a post earlier this week, the Institute of Medicine really started the modern day patient safety movement with this report that outlined where medical errors were occurring and how to stem the tide.
The series of blog posts has hosted commentary from national healthcare leaders as well as researchers and providers, all discussing any progress that has been made since the report was originally published. INQRI itself is a program funded by the Robert Woods Johnson Foundation that supports interdisciplinary teams of nurses in their efforts to improve patient care. It’s leaders, Mary Naylor, PhD, RN, FAAN and Mark Pauly, PhD, were part of a Q & A on the blog as was Janet Corrigan, PhD, MBA, president and CEO of the National Quality Forum. There is even a multimedia clip from the TV show “Grey’s Anatomy” illustrating the horror of discovering a medical error.
It’s been 10 Years since “To Err is Human”; has patient safety improved?
November 2009 marks the ten year anniversary since the Institute of Medicine (IOM) released its groundbreaking ‘To Err is Human’ report, bringing to light the staggering number of medical errors and resulting preventable deaths that occur in U.S. hospitals each year (that report put the number at 98,000). Since then, entire organizations have been formed, laws passed, and new ways of thinking incorporated into healthcare in an effort to reduce this number. There has been much positive change.
My colleague Cheryl Clark at HealthLeaders Media published this article today that spells out some of the areas in which the healthcare industry has improved patient safety, as well as some of the areas that could still use attention. Some of the bright spots: Certain states have taken the lead on creating tough reporting laws and mandating detailed incident reports. The Institute for Healthcare Improvement has helped thousands of hospitals collaborate with each other and use best practices to reduce patient harm with its various campaigns. Healthcare providers have joined together to decide on common medication labeling practices to reduce the number of medication errors. The CMS will no longer reimburse hospitals for specific adverse events. There’s been a detailed look at how the culture of an organization can drive the performance of its staff members. I’d also add to this list that the AHRQ has played a huge role in funding patient safety research and spurring projects in the name of healthcare quality.
However, many adverse events continue to occur, despite the efforts of many within healthcare. The article names surgical safety, infection control, and medication safety as three areas to which more attention needs to be paid if we want to take a 20-year look back and find that even more progress has been made. I think that along with these issues is the topic of how technology will come to effect them as well. How will EMRs/ CPOE effect infection control and monitoring?
Do you think that the industry has shown significant progress since the IOM report was issued 10 years ago?
