Tag: medical error

Have a Safe and Merry Christmas!

The Physician-Patient Alliance for Health & Safety wishes you, your family and friends a safe and merry Christmas.

Have a Safe and Merry Christmas!
Have a Safe and Merry Christmas!

While we don’t want to be alarmist, we hope that you are not admitted to a hospital this holiday season.

The Institute of Medicine in its 1999 report, “To Err Is Human” estimated 98,000 people a year die because of medical errors. Recently, John James, PhD reviewed the literature. Using a weighted average of four studies, he found annually at least 210,000 patient deaths were preventable harms in hospitals.

We invite you to watch our clinical education podcasts to hear the latest practices and recommendations from healthcare experts on how to keep you patients safe.

Organizations Need to Collaborate To Improve Patient Safety

In an article published on March 13, the National Patient Safety Foundation (NPSF) announced the first day of Patient Safety Awareness Week, as well as their merger with the Institute for Healthcare Improvement (IHI). Most importantly, the now-joint organizations restated a potent call to action: that preventable health care harm is a public health crisis and requires a coordinated public health response.

The Physician-Patient Alliance for Health & Safety (PPAHS) echoes the call of NPSF and IHI for healthcare leaders to treat every week as patient safety week by initiating a coordinated public health response to improve patient safety and drive the collective work. Doing so would help ensure that patients, and those who care for them, are free from preventable harm.

Directly targeting preventable harm at the clinical level is a deeply interconnected – and nuanced – problem. It will take the concerted efforts of many stakeholders:

  • Clinicians, key to the development and implementation of patient safety initiatives and sharing their successes and failures.
  • Hospital administrators, capable of empower doctors, nurses, and other specialists by providing them with the resources to continuously improve quality of care.
  • The academic community, who can ensure that patient safety interventions are high-quality through peer review.
  • Patient safety organizations like the IHI and PPAHS, who can examine the big picture, spot trends, and call attention to highlights and lowlights.
  • Public health agencies at the state and federal levels, who can transform the efforts by stakeholders described above into policy.

Most importantly, it will also involve actively engaging patients, who can play an active role in ensuring the safety of their own care by knowing their medical history, understanding which questions to ask, speaking up when something does not seem right, and following the instructions of their doctors and nurses.

Integrating stakeholders from across all of these groups is essential for the success of any coordinated public health response. This is a key reason why the PPAHS Board of Advisors consists of representatives from each of these stakeholder groups. It is also why we choose to work in tandem with other organizations on priority areas such as respiratory compromise: initiatives need to involve multiple stakeholders who bring with them diverse perspectives and skill sets.

The Respiratory Compromise Institute (RCI) embodies this level of coordination. Consisting of members such as the Society of Hospital Medicine, American Association for Respiratory Care, and CHEST/American College of Chest Physicians, RCI is a collaborative effort to improve opioid safety.

A recently-released report by RCI exemplifies the outcome of coordination and collaboration. The report identifies eight distinct subsets of respiratory compromise that pose a high risk of patient harm – and, most importantly, could be prevented with early detection and intervention. The manuscript is the result of a workshop organized by the National Association for the Medical Direction of Respiratory Care to address the unmet needs of respiratory compromise across the clinical spectrum. The writing committee was comprised of a diverse set of clinicians focusing on respiratory ailments – a collaborative group consisting of doctors, nurses, and respiratory therapists. Read the report here.

These kinds of reports are just one step in improving patient safety and help set direction for coordinated responses. It is up to us as a public health community – clinicians, administrators, patient safety organizations, public health agencies, as well as patients – to use this knowledge and take action to transform the standard of care in hospitals across the nation.

Improving the Management of Medical Error

By Betsy M. Cohen (Certified and Licensed Rehabilitation Counselor)

I have been a rehabilitation specialist and case manager working with patients who have neurological and neuropsychiatric impairments for thirty years. About three years ago, my life took an unanticipated detour when I was perforated during a baseline colonoscopy. The doctor explained that she was running late and didn’t follow standard procedure at the time I was perforated. All of my experience as a case manger and patient advocate could not prevent this error or the others that followed; ignored symptoms of an infection that became a large abscess and nerve damage during a procedure to drain the abscess. Continue reading “Improving the Management of Medical Error”

Is it Luck or Medical Error when a Patient Dies? – Weekly Must Reads in Patient Safety (Jan 8, 2016)

When patients die in hospital, is it because their are unlucky or is it due to medical error?

Reflecting on the 15th anniversary of Institute of Medicine’s 1999 report, “To Err is Human”, Maryanne McGuckin, Dr.ScEd, FSHEA recently wrote:

Continue reading “Is it Luck or Medical Error when a Patient Dies? – Weekly Must Reads in Patient Safety (Jan 8, 2016)”

Monitoring can prevent errors with patient-controlled analgesia

by Laura Batz Townsend

My Mom, Louise Batz, died from a preventable medical error after recovering knee surgery. Mom went into the hospital for knee replacement surgery.

This was not emergency surgery. She had planned the surgery so she would have enough time to heal and be ready to welcome the arrival of her fourth grandchild. Continue reading “Monitoring can prevent errors with patient-controlled analgesia”