lapses in sterile technique may result in an infection.
•Maternal deaths: obstetrical deliveries may result in injury or death.
•Medical equipment: medical equipment failures may result in disability or death.
•Medication error: physician, pharmacist, or patient error may result in injury or death due to improper or wrong medication use.
•Operative/post-operative: complications may result from surgical or post surgical care.
•Patient abduction: infant abduction from newborn nurseries have occurred.
•Patient falls: the failure to identify the fall-risk patient, and/or the failure to safeguard the patient may have serious consequences.
•Perinatal deaths/injury:injuries or death may occur around the time of birth.
•Potassium Chloride: the accidental direct intravenous injection of potassium chloride can result in cardiac arrest.
•Restraint deaths: restraints are a last resort to protect patients from themselves and staff from patients. Restraint use is only for the shortest time necessary and includes frequent monitoring. Failure to monitor these patients may result in medical complications or death.
•Suicide: guidelines must be in place to identify and monitor the suicidal patient.
•Transfusion: an improper matching of a blood transfusion can cause injury or death.
•Ventilator: mechanical ventilation is often necessary to breathe for patients who are unable to breathe for themselves. Improper ventilator settings, machine failure and incomplete monitoring may result in death.
•Wrong site surgery: wrong-site surgery can result from failure to identify the precise surgical site.
•Wrong test performed: improper orders or failure of interpretation of orders will result in the wrong test.
Medical errors do not only 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:
1)Living alone
2)Absence of a working smoke detector
3)Flammable clothing
4)Home oxygen
5)Cognitive impairment
6)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 important 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.
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 problems.
•Speak with the physician;
•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 patient who will adhere to a well-planned proper course of action.
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.
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
