According to patientsafetymovement.org (2013), over 200,000 patients die each year due to preventable causes. This is more than the number of deaths from lung, breast and prostate cancer combined. With such a high number of patients at risk of preventable death, the idea of patient safety moved to the forefront of medical discussions in the early 1990’s with the release of the Institute of Medicine’s report To Err is Human. The report brought to light the issues of patient safety and the errors occurring every day in medical facilities across the country.
Patient safety as defined by the Institute of Medicine is simply stated as having “freedom from accidental injury” (ahrq.gov). Patient safety is now considered a healthcare discipline concerned with reporting, preventing and analyzing adverse events in an effort to reduce or eliminate errors leading to undesirable patient outcomes. Some of the most common medical errors affecting patient safety are wrong site surgery, medication errors, and health care acquired infections.
Other causes of medical errors are not directly related to “touching” the patient.
These errors include hand-off communications, illegible handwriting, and poor coordination of care. Wrong site surgeries include operating on the wrong part of the body, performing the wrong operation, or operating on the wrong patient. While wrong site surgery is rare, (from 1995-2010, the Joint Commission received reports of 956 wrong site surgeries), it is probably one of the most preventable injuries affecting patient safety (National Patient Safety Foundation, 2014). Medication errors occur if a patient receives the wrong medication or if the patient receives the right medication in the wrong dose or wrong form.
One of the most common errors facing the patient safety movement today, the Institute of Medicine estimates medication errors affect over 1.5 million Americans each year (NPSF, 2014). Health care acquired infections are infections occurring in patients while being treated for other medical conditions. These infections can be acquired while being treated in or out of a hospital setting.
Each year in the United States, approximately 1 in 20 patients contract a health care acquired infection. Errors in patient hand-off communications account for an estimated 80 percent of serious medical errors (patientsafetymovement.org, 2014). A lack of effective communication is responsible for these avoidable adverse events. Illegible handwriting leads to the misinterpretation of physician orders and has led to medication and treatment errors. Patients are at risk for error whenever more than one healthcare provider is involved in their care. Not all providers may have had access to the same information and this lack of coordination of care can result in medical error. In order to develop a patient safety culture in healthcare institutions across the country, several groups were created or formed to outline new patient safety initiatives as well as define the actions both providers and patients can take to prevent medical injuries due to preventable errors.
One such group, the Agency for Healthcare Research and Quality, (AHRQ), “is a home to research centers that specialize in major areas of healthcare research such as quality improvement and patient safety . . . and delivery systems (Pozgar, 2012, p. 541). The AHRQ is charged with the following initiatives: 1. Identify the causes of preventable health care errors and patient injury in health care delivery. 2. Develop, demonstrate, and evaluate strategies for reducing errors and improving patient safety. 3. Disseminate such effective strategies throughout the health care industry.
As the AHRQ works to meet its initiatives, other groups such as the National Patient Safety Foundation establish action plans to address the challenge of eliminating medical errors. For example, in 2013, the foundation addressed nine areas in which patient safety errors occur and how these errors could be eliminated by following a well-developed plan. Included in those nine areas were medication errors, hand-off communication errors, and healthcare associated infections (patientsafetymovement.org). Other results of the patient safety movement include the way patients are identified. For example, two patient identifiers are used prior to providing patient care. These identifiers may include a patient’s name or date of birth. These identifiers are then matched to the patient record thereby ensuring treatment is provided to the right person.
Many providers and facilities have strict infection control guidelines including the use of hand washing and proper use of PPE (personal protective equipment), such as gowns, gloves, and masks. Other changes relate to the elimination of medication errors. For example, look alike or sound alike drugs are kept separated or repackaged in pharmacies to prevent giving a patient incorrect medications. In order to prevent wrong site surgeries, both the physician and the patient are involved in clearly marking the site prior to surgery as well as verbal communication between physician and patient as to the surgical site and what type of surgery the patient is about to undergo. Other safety actions include the members of the surgical team taking a “time-out” prior to surgery to confirm the correct patient, correct site, and correct procedure (Pozgar, 2012). Another initiative began in 2005, when Dr. Donald Berwick and the Institute for Healthcare Improvement, (IHI) created a campaign to save 100,000 lives (Levin, 2005, p. 94).
“The campaign aims to enlist at least 1,500 hospitals across the United States to commit to six key evidence-based, safety and quality improvements that have the potential to save 100,000 lives over the next 18 months—and beyond” (Levin, 2005, p. 95). The six key-evidenced based improvements are 1. Rapid Response Teams. 2. Prevention of Central Line associated bloodstream infections. 3. Prevention of surgical site infections. 4. Prevention of adverse drug events. 5. Improved care for acute MI. 6. Prevention of ventilator associated pneumonia. Dr. Berwick and the IHI believed that this initiative could be successful at preventing patient medical errors and result in an unknown number of saved lives. The overall goal of all groups involved in the patient safety movement is to improve the quality of patient care through system improvement, education, and shared experiences to reduce the risk of medical error.
Unfortunately, the goals of the patient safety movement and the current tort system do not go hand in hand. While the patient safety movement encourages open communication regarding patient medical errors, the risk of litigation causes many healthcare providers and institutions to remain silent regarding patient medical errors. In order to avoid lawsuits, many physicians practice “defensive medicine,” which can actually increase the risk of patient medical errors resulting in malpractice lawsuits. Some tort reforms have shown to be somewhat successful in reducing the overall cost of liability by keeping insurance premiums lower, keeping physicians in practice, and capping the amount of damages paid to patients. However, while these reforms may have reduced the financial burden on healthcare providers, they do little to support the patient safety movement. The most widely cited concerns about the medical liability system relate to the system’s impact on costs and access to liability coverage, its impact on patients’ safety, and the administrative burden of litigation. According to AHRQ, in order to address these concerns, the following reforms have been discussed:
Full disclosure/early offer programs.
Certificate of merit programs.
Caps on damage awards, periodic interim payment rules, joint and several liability reforms, collateral source rule reform, and the abolishing of punitive damages.
Pre-trial screening panels.
Health courts
Patient safety is one of the primary goals of reform efforts that focus on programs that promote full disclosure, early offers, and the collection and analyses of the root causes of medical errors (AHRQ, 2010). As with all movements, the patient safety movement is not without its critics. One criticism of the movement deals with physician burnout. The patient safety movement includes many new initiatives aimed at improving patient safety. Each of these new initiatives takes time to understand and implement in order to have the desired outcome. Unfortunately, many providers are faced with learning these initiatives on top of an already full day of patient care. Most facilities have not built in the time required to learn, understand, and implement new initiatives.
At the time the IOM published the To Err is Human report, many in the healthcare field questioned the numbers revealed in the study as well as contending that the information in the report would focus undue attention on accidental deaths and prevent limited resources from being directed at other important quality improvement initiatives. Other critics do not agree with the focus on involving patients in their own care, believing that if a patient is already sick and in the hospital, the patient should not have the additional burden of making sure they are receiving the right medicine at the right time, etc. Whether a supporter or critic of the patient safety movement, everyone can agree that human errors do occur in the treatment of patients. In order to improve patient safety, healthcare providers and facilities must continue to find ways to implement new initiatives that improve the overall quality and safety of the care provided to patients.
References
AHRQ. (2008). What Exactly Is Patient Safety? Retrieved from http://ahrq.gov Institute of Medicine. (2014). Retrieved from http://iom.edu/ Levin, A. A. (2005). Patient Safety- Rejecting the Status Quo. NC Med J March/April 2005, Volume 66, Number 2. Retrieved from http://ww.ncmedicaljournal.com National Patient Safety Foundation. (2014). Key Facts About Patient Safety. Retrieved from http://www.npsf.org/for-patients-for-consumers Pozgar, G.D. (2012). Legal Aspects of Health Care Administration (11th ed.). Sudbury, MA: Jones & Bartlett Learning, LLC The Patient Safety Movement. (2013). Challenges & Solutions. Retrieved from http://patientsafetymovement.org/challenges-&-solutions-/
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