The Need For Patient Safety And Fewer Medical Mistakes

It could be the wrong medication or the wrong dose. The wrong patient underwent a test or a procedure scheduled for another person. Was it the consequence of illegible handwriting, miscommunication, or malfunctioning equipment? It does not take much to make a mistake. Mistakes happen to everyone in the course of a workday, every day of the week. But when the workplace is a hospital, pharmacy, or doctor’s office, those mistakes become headlines.

In 1999 the Institute of Medicine, a research arm of the National Academy of Sciences, reported that 4,000 to 98,000 people die each year in hospitals because of mistakes by medical professionals and many more are injured.

As a result, hospitals across the country are beginning to acknowledge that accidents happen and only by recognizing that can patients be made safer.

Yale-New Haven Hospital has been engaged in a hospitalwide effort to make patient safety an everyday, every-hour activity for the past two years. That was when YNHH established a patient safety steering committee under the direction of its chief of stall, Peter N. Herbert, MD. The initiative targets key patient safety issues like patient misidentification, medication safety, and hospital-acquired infections. The committee’s goal is to help the hospital improve the procedures in place for patient identification, correct blood labeling, medication variance reporting and hand hygiene.

Registered nurse Sally Roumanis, a co-chair for patient safety initiatives, said that within the past year, more than 20 patient safety performance improvement projects were successfully completed. This year the hospital is targeting areas such as MRI safety, surgical safety, fall injury prevention, and the development of an electronic error reporting system.

“The definition of patient safety at Yale-New Haven is ‘freedom from accidental injury,’” said Ms Roumanis. “We have made great strides in known risk areas –– for example, our last quarterly report showed that 99.9 percent of blood specimens were properly labeled –– to try to ensure that our patients have a safe, secure experience in our hospital. If we work together, we can make Yale-New Haven an exceptionally safe place for patients.

“While hospitalization always involves some degree of risk, that risk can be reduced when patients and their families become as aware and informed as possible,” said Dr Herbert. “Research shows that patients who are more involved with their care tend to get better results.”

With a strong belief that communication is the most important aid to patient safety, YNHH encourages patients to ask questions and be assertive. The hospital also encourages patients to become active partners by educating themselves about infection control and disease prevention. Information is also the best weapon against medication errors, equipment and treatment errors, and cases of mistaken identity. Yale-New Haven Hospital has produced a fact sheet called, “Staying Safe in the Hospital,” to make patients and consumers more aware of and involved in hospital safety. Each YNHH patient is given a copy of the fact sheet in the admitting office. For a free copy of YNHH’s fact sheet on patient safety, call 203-688-2488.

For information on how to reduce medication errors, ask for a free copy of Yale-New Haven Hospital's Making the Right Choice fact sheet called "How to Avoid Medication Errors" or call 203-688-2000 or toll-free 888-700-6543 for a copy.

But a recent report in the Journal of the American Medical Association shows the problem goes beyond fatal errors in hospitals. About one in five older Americans receives at least one potentially inappropriate prescription drug, the report says.

A new nonprofit group, the Patient Safety Network, is working to change that. The group plans to use the latest in computer technology to reduce the number of medical errors plaguing the US health care system.

The computer technology already exists that could retrieve information about a patient from many sources. The idea is to make this information readily available without compromising patient confidentiality. This requires linking different information systems and persuading doctors and hospitals that keeping records electronically has benefits.

By reducing medical errors, inappropriate hospital admissions, and other forms of unneeded treatment, the system could save millions of dollars, according to the network supporters, while at the same time providing more effective, safer medical treatment for patients.

The Patient Safety Network, based in California, plans to test its system this year.