Medical Errors: 5 System Wide Changes That Can Prevent Patient Harm

fiercehealthcare
May 13, 2016 | By Ilene MacDonald

[ED; here's one approach which would obviate a good 90% of the problem.]

• Nursing (5)
• The Law (13)
• State Medical Boards (6)

Treat principles in the case as principles in the case.
https://www.law.cornell.edu/uscode/text/18/4

Despite controversy over the definition of medical errors used in a new study that finds these mistakes lead to 10 percent of deaths in the United States each year, it's clear that the industry has to do something to catch and prevent these errors.

As many as 250,000 deaths occur each year due to a medical mistake, according to The BMJ study, confirming previous research from 2013. That's roughly 685 people a day.

I can't imagine that we'd turn a blind eye to these statistics if that many people died each day in plane crashes.

But it looks like the industry and the media are finally paying attention.

In addition to the study findings, this week The New York Times reported that the family of comedian Joan Rivers settled a medical malpractice lawsuit against a New York City clinic after a federal investigation indicated her death was due to aseries of errors.

Fortunately, not all medical mistakes lead to death or serious injury. But many of these errors are preventable. For instance, a year-long investigation into medical errors involving cataract surgery in Massachusetts found cases where the wrong lens was implanted, procedures were performed on the wrong eye or wrong patient and anesthesia was incorrectly administered.

The report, released yesterday by the Betsy Lehman Center for Patient Safety and Medical Error Reduction, found that the surge in errors involved "never events" that are entirely preventable. And these are cases that involved the most common surgery performed in the country and a procedure that is also considered among the safest.

The investigators called on surgeons, anesthesiologists, nurses, technicians and administrators to examine their current practices and implement steps to prevent these adverse events from happening again.

The report found that these mistakes were due to system-wide errors, such as breakdowns in communication and failure to conduct an effective time out. The BMJ study also indicated that most medical errors were due to systemic problems, such as inadequate coordination of care and the absence of safety nets.

And while the study focused on cataract surgery, the panel's recommendation to prevent these errors from happening again are applicable for all procedures and to all healthcare institutions:
Foster a culture that makes the prevention of patient harm a top priority
Engage physicians and staff to develop and implement a patient safety program
Standardize and adhere to protocols and processes, including effective times outs
Conduct a meaningful, informed consent process that engages patients
Recognize that even the best systems require continuous improvement to address emerging risks

Perhaps these steps would have saved the life of Joan Rivers. Her daughter, Melissa Rivers, told CNN that she intends to ensure no one has to go through what her family endured, vowing to work toward "ensuring higher safety standards in outpatient surgical clinics." --Ilene (@FierceHealth)

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Medical errors officially the third leading cause of death in U.S., study finds


Thank You Ms MacDonald and FH.