Control of concentrated electrolyte solutions
Potassium chloride (KCL) is the culprit here. In the first two years of keeping such records, ten patients died by the direct intravenous administration of the concentrated solution of potassium chloride. The nurse or pharmacist adds small amounts of this concentrated solution to a liter of IV fluid to make a very dilute KCL solution used to treat low potassium levels. However, if given undiluted, the medical error is irreversible—death is the outcome. For this reason, KCL is banned from hospital nursing units. It is designated a controlled substance like narcotics, and can only be kept in the pharmacy under many safeguards including limiting who may handle it. Each vile is required to carry a label stating HIGH RISK and MUST BE DILUTED. If patients are ever to receive potassium as therapy, they must know how to administer it. If oral tablets, there is no problem if taken as prescribed.
Catheter and tubing connections
Very ill patients may require multiple catheters and tubes used for drainage of body fluids and as portals of entry to deliver necessary medications. Personnel have made misconnection errors resulting in wrong medication delivery to the wrong body site. Nine such cases reported resulted in eight deaths and one loss of function. The Joint Commission has recommended preventive measures that all hospitals must adopt. They include:
•Labeling of all high risk catheters such as those that enter the spinal canal or an artery
•Staff must always trace a tube or catheter from its point of origin to the patient before connection is made with a new device or an infusion
•When a patient arrives at a new setting, staff must always recheck and trace all patient tubes and catheters from their source
•Staff must route tubes and catheters having different purposes in different directions
•Non-clinical staff, patients and families must get help from clinical staff whenever there is a perceived need to connect or disconnect infusions or devices
•High-risk catheters must be labeled and not have injection ports
Infection control
There are estimated 1.7 million infections in United States hospitals per year resulting in 99,000 deaths. These infections are urinary tract (32%), surgical site infections (22%), pneumonia (15%), and bloodstream (14%). There have been twenty-eight different organisms acquired in hospitals.
Hospital acquired infections, also known as nosocomial infections occur in five percent of all hospitalized patients. There are many reasons for this scary statistic:
Many hospitalized patients have weakened immune systems making them more susceptible to infections
•They may have a weakened immune system because they have an illness causing this increased susceptibility, or they are receiving treatment that weakens their immune system. The end-result is decreased resistance to bacterial, viral, or fungal infections
•Medical procedures can introduce infectious agents into a patient
•Patients admitted with infectious diseases may transfer the infection to other patients
•Hospital workers and visitors are also susceptible to infections acquired from patients
•The same principles apply to all healthcare organizations including nursing homes, clinics, dental and other healthcare offices, child care centers, homes, restaurants, and schools
Healthcare workers can carry antibiotic resistant bacteria, viruses and fungi on their hands. Proper hand hygiene will reduce the incidence near 100 percent. Washing with soap and water can be effective if done well, but it is time consuming. Done with every patient interaction, it can result in significant dryness and irritation to the hands. Therefore, hospitals have introduced an alcohol rub hand washing system that can kill bacteria in fifteen seconds, can reduce bacteria count 10,000 fold and is gentle on the hands. If hospital personnel do not wash their hands before examination, the patient must insist they do. All physicians should place a sign in their examining rooms—“Don’t be afraid to ask if I’ve washed my hands.”
The overuse of antibiotics has resulted in bacterial resistance to common antibiotics. This may result in failure of treatment for an infectious disease. A more rational use of antibiotics based upon treatment guidelines followed by physicians and accepted by patients will reverse this trend.
Diagnostic errors and failure to diagnose
Failure to diagnose is a common problem. Forty percent of malpractice cases fall under this heading. The fault lies with patients, doctors and even insurance companies:
Patients are at fault when they never see a doctor, ignore mild, or not so mild symptoms and refuse diagnostic studies.
Doctors are at fault when they do not make the time necessary to take a thorough medical history and perform a complete medical examination. They are so busy with follow up care and acute care medicine that the initial thorough review can get short-circuited. Patients can play a vital role in prevention here. If it is felt that an initial examination has been incomplete, never be afraid to ask. Oversee the complete examination process. Step 2 of this book will tell what it entails.
Insurance companies may cause delays in diagnostic testing.
These are but a few of the problems that can lead to failure to diagnose.
The Joint Commission has recommended patient safety standards for all healthcare organizations. They undergo a yearly review and every organization will adopt these standards. Safety standards are in place for the following healthcare organizations:
Ambulatory care and office-based Surgery
Assisted living
Behavioral healthcare
Critical care hospital
Disease-specific Care
Hospital
Home care
Laboratory
Long-term care
Networks
The Joint Commission publishes these standards on their web site: JCAHO.org.
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