happen within hospitals. They can occur in any healthcare facility including outpatient surgery centers, clinics, doctors’ offices, nursing homes, pharmacies and patient’s homes. In fact, home care fires are another sentinel event claiming victims over age sixty-five in most instances. Risk factors identified are:
Living alone
1)Absence of a working smoke detector
2)Flammable clothing
3)Home oxygen
4)Cognitive impairment
5)Smoking has been a factor in all cases reported
An incomplete medical history and physical examination will result in failure to diagnose. The same is true of an incomplete screening laboratory analysis and risk factor analysis. This is a crucial part of any physician-patient interaction from the diagnostic standpoint, and there is nothing more important for creating rapport and a lasting, trusted relationship between the physician and the patient.
When a medical error has occurred there has been a breakdown of one or more of the built-in safety measures put in place to prevent such mishaps. These safety measures are the responsibility of the entire healthcare team. Physicians must get involved by making certain that patients are educated and made to take responsibility for their care. Patients must understand that they are not a passive member of the team. They are the most impopatrtant member. They must feel free to ask questions and satisfy themselves that the medical diagnostic and treatment option they choose is the best one taken for an optimal result. They must take control!
There are basic steps any patient must take when confronted with a new diagnosis that has long-term future impact. These are:
Learn all that is possible about the problem or problem
•Speak with the physician or other member of the healthcare team
•Get information from the internet or books
•Look to support groups for assistance
Only then will patients be in a position to decide upon a treatment plan. Physicians want their patients to do this. Careful evaluation of all the risks and benefits will produce a satisfied and fully informed patient who will adhere to a well-planned proper course of action, best suited to their individual mind-set.
Medical errors are:
•Medication prescribing and use
•Medication use during care transitions
•Patient identification
•Performance of correct procedure at correct body site
•Communication during patient handovers
•Control of concentrated electrolyte solutions
•Catheter and tubing connections
•Infection control
•Diagnostic errors or failure to diagnose
Patients can and must assist in prevention. This book will provide clinical examples that illustrate the error discussed and the patient’s role in prevention.
Medication prescribing and use
When a physician writes a prescription, it must be legible. If it is not, the pharmacist may have difficulty. If a patient cannot read the prescription, rewriting it is mandatory, or, at least, spelled out in writing. Sound-alike medications with similar spelling have been confused, so patients must be alert less they receive the wrong medication. There are also look-alikes, and generic medications made by different manufacturers may have a dissimilar appearance. Therefore, the moral of the story is—if there is an issue about any medication, clarify it before taking the medicine.
The busy pharmacist could misread the medication or confuse it with a medicine with a similar sounding name. The use of pharmacy technicians is common. Failure of the pharmacist to check everything the technician does has also caused prescription errors. This complicated process must be double-checked.
When a physician sees a patient, the patient should bring a list of all medications prescribed by all physicians. Some larger clinics and University Medical Centers will have a full medication list printed out for patient evaluation and confirmation. If not, then patients must come prepared either with a full medication list including vitamins, herbs and dietary supplements, or with a brown-bag with the medications. Physicians will appreciate this help and realize they are dealing with an educated and informed patient. Patients must be wary of physicians who do not think this way.
Example: A patient suffered from sleep apnea that she could not control with the recommended C-pap therapy. This is a breathing assist mechanism to prevent obstructive breathing. A dental appliance, another form of therapy, also did not help. The patient did much of her own research, and was more aware of all the physiological mechanisms of sleep apnea then most physicians. Out of desperation, she saw another doctor in consultation. And when the patient told this doctor about all the research she had done to understand her illness, the doctor stopped her and asked, “You do research on sleep apnea? The astounded patient said, “I want to know about my problem.” “That’s the doctor’s job.” he said, “That’s not for patients to do.” Her inclination was to get up, say thank you, and leave, but she did not. She asked me what I thought. I told her, at that point, you would have lost all confidence in that doctor, and I would not have blamed you if you did just as your inclination suggested, thank him, left, and found another doctor.
Patients must be certain that every physician they see in consultation is aware of any medication allergies. This is the only way to avoid receiving a medication that may cause harm. No physician can know what any patient may or may not be allergic to. Prescribing medication is a gamble, and will remain so until the era of personalized medicine (see appendix 3). At this time, a doctor does not know what any medication’s effects will be on any individual patient.
Case in point:
A patient had open-heart surgery. His doctors prescribed numerous medications. Prior to surgery his blood count was normal, and after surgery his blood count was reduced. The blood loss during surgery should have resolved and gone back to normal within weeks of the surgery, but it did not; in fact, it continued dropping to lower levels. His doctor sent him to a hematologist who, thinking of all kinds of rare diseases, recommended that he have a bone marrow biopsy. The patient decided to hold off on this procedure while he did his own personal research. He went on the internet and studied his medications, all of whom had the rare potential of causing anemia. Could this be it, he thought? Is one of the medications causing this? After understanding the possible risks of delay and getting approval from his doctor, he stopped the last medication prescribed that was for prostate symptoms and repeated his blood count after one month. Lo and behold, it was back to the pre-surgical and normal fifteen grams. He had had a rare side effect of a medication prescribed for his enlarged prostate. This information now occupies a prominent place on his medical chart. He saved himself a bone marrow biopsy, and his hematologist learned something too.
If patients are allergic to any medication, it is wise to wear a wristband identifying the offending agent.
Patients must know the following when given a prescription:
•What is the medicine and what does it do?
