Foundation aims for error-free environment
Here are 9 more ways to curb mistakes
Getting physicians and staff to admit mistakes might sound like an impossible ethical dilemma, but it could be eliminated if one organization has anything to do with it.
The National Patient Safety Foundation was formed in May 1997 by the Chicago-based American Medical Association to create a health care environment where accidental patient injuries and deaths no longer occur. The foundation now is an independent organization.
The foundation wants to examine mistakes and how they occur under a microscope, says Martin J. Hatlie, JD, an attorney who serves as executive director of the foundation.
"The unethical or incompetent physician is a very small part of the problem," Hatlie explains. "There are programs out there to identify these people and rehabilitate them or restrict them. But how can we help the good doctor, nurse, or pharmacist who’s involved in these mistake scenarios? The mistakes are essentially breakdowns in the system, and that’s the gap we want to address."
Eliminating mistakes or even just reducing them could have a substantial impact on lowering a hospital’s risk, Hatlie adds.
According to the foundation’s internal research, the number of injuries caused by medical mistakes in hospitals nationwide could be as high as 3 million and result in costs as steep as $200 billion, says Lucian Leape, MD, a pediatric surgeon and professor of health policy at the Harvard School of Public Health in Cambridge, MA. Leape also is a foundation board member.
Taking these steps is a start
Ethics committees can help foster an error-free health care environment by implementing steps recommended by the foundation, says Hatlie. While some steps are easy to implement, others might be more difficult and could take longer to put in place, he warns.
The National Patient Safety Foundation recommends the following steps to an error-free work environment:
1. Physicians should routinely practice crisis management skills in realistic simulations and use computerized dummies for patients.
2. Hospitals should use electronic medical records that would eliminate errors related to a physician’s illegible handwriting.
3. Prescription orders, including those from physicians’ offices, should be entered into a computer program that can:
remember that a patient is allergic to certain drugs even if the prescribing physician forgets;
provide facts, such as other medications the patient is currently taking, that may interact with the new medication.
4. Staff should use bar code technology, similar to the kind used in supermarkets, to track med-ications given to patients during the hospital stay.
5. Hospitals should not permit double shifts or other unrealistic work schedules for interns and residents.
6. The use of concentrated potassium chloride, which the foundation attributes to the cause of five to 10 hospital deaths per year, should be discontinued.
7. Physicians and nurses should work in teams to understand how to support and help each other.
8. Medications should not have similar labels, and equipment should be designed to eliminate the possibility of harmful results, such as features that make it possible for intravenous solution connections to fit connections for gastrostomy tubes.
9. If a mistake does occur and patients are injured or killed, the question should be changed from "Who did it?" to "Where did the system fail?"
There’s still room for improvement in dealing with incompetent physicians on an individual basis as well, Leape concedes. Currently, hospitals and patients rely on state boards of registration and the court system, both of which are limited, he notes.
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