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How Clinicians at Nine Hospitals Cut Medical Errors by Almost a Third—and Other Strategies to Reduce Medical Mistakes

Created Aug 20 2014, 08:00 PM by Lippincott Solutions
  • incompetent physicians
  • preventable mistakes
  • medical errors
  • patient safety

Thursday, August 21, 2014

Medical errors are now suspected to cause a staggering 440,000 patient deaths a year in U.S. hospitals, according to a study published in the September 2013 issue of the Journal of Patient Safety. Among Americans, preventable medical errors in hospitals are currently the third leading cause of death. Only heart disease and cancer claim more lives.

Outside hospitals, the problem continues. Preventable mistakes such as missed diagnoses and medicine-related harms are suspected of claiming tens of thousands of outpatient lives annually.

 “Medical harm is a major cause of suffering, disability, and death—as well as a huge financial cost to our nation,” said Senator Bernie Sanders, chairman of the Senate Subcommittee on Primary Health and Aging, during a July 2014 hearing on the matter.  “This is a problem that has not received anywhere near the attention that it deserves.”

Most Common Preventable Mistakes

Becker’s Hospital Review recently published a list of the most common medical errors. In order of occurrence, they are:

  • adverse drug events
  • catheter-associated urinary tract infection
  • central line-associated bloodstream infection
  • injury from falls and immobility
  • obstetrical adverse events
  • pressure ulcers
  • surgical site infections
  • venous thrombosis
  • ventilator-associated pneumonia.

Increased Patient Participation Could Reduce Risk

With awareness of the extent of medical errors growing, conversation is turning to how to improve the situation. The writers of the Journal of Patient Safety study suggest increased participation by patients in their care.

“Perhaps it is time for a national patient bill of rights for hospitalized patients that would empower them to be thoroughly integrated into their care so that they can take the lead in reducing their risk of serious harm and death,” the authors write. “All evidence points to the need for much more patient involvement in identifying harmful events and participating in rigorous follow-up investigations to identify root causes.”

Holding Bad Doctors Accountable

In an op-ed column published recently in the Los Angeles Times, retired neurosurgeon Philip Levitt recommends better policing of incompetent physicians.

“Most preventable mishaps in hospitals are caused by the acts of individual practitioners,” he writes, highlighting research that found that 50% of medical malpractice payouts over a 20-year period involved 2% of U.S. physicians.

However, he continues, a mere 0.04% of physicians lose their licenses annually—a rate that would require some 50 years to remove “the most dangerous 2% of doctors.”

“The institutions meant to protect patients from inept physicians are not doing an adequate job,” he warns.

Cultivating Communication During Hand-Off

Meanwhile, caregivers at nine U.S. hospitals reduced injuries due to medical errors by an attention-worthy 30% by improving communication during patient hand-offs. They published their study in the Nov. 6, 2014, New England Journal of Medicine.

Some 80% of serious medical mistakes involve miscommunication when patient care is transferred—or handed off—from one caregiver to another during shift changes. To address this, the researchers introduced a hand-off process that included the verbal mnemonic “I-PASS” (illness severity, patient summary, action list, situational awareness and contingency planning, and synthesis by receiver) and a written handout that reflected the verbal mnemonic.  

Standardizing communication between the “givers” and “receivers” worked to reduce medical mistakes.

“A great medical team is like a great relay team,” said Arthur Kellermann, MD, dean of the Uniformed Services University of Health Sciences F. Edward Hébert School of Medicine, which created the I-PASS hand-off bundle with Walter Reed National Military Medical Center.

“Individual effort matters, but victory comes from smooth hand-offs.”

 

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