this patient not taken charge of her own health, a medical error would have occurred; a test already done that could not identify the cause of her bleeding would have been repeated; twenty-two hundred dollars would have been wasted, and a serious diagnosis would have been delayed—and that delay had the potential for great harm. You can also see the wasteful financial impact that might have occurred. Is there any wonder that our medical care system could break the bank?
The truth of the matter is—medical errors occur because systems break down. Some of these errors lead to delays, a waste of money, injury—and some lead to death. The healthcare system with its conflicting insurance rules, approved hospitals, unapproved hospitals, approved doctors, doctors not on the list, approved and unapproved testing facilities, different reimbursement formulas, and necessity for approvals from non-medical personnel, is cumbersome and complicated and the patient is in the middle and that is why patients must direct their care. Patient safety, life, limb and financial well-being are all at stake. With the healthcare changes to come what will happen to this already overburdened system?
Because this patient took charge of her health, she had an exact diagnosis established: venous angioma, an untreatable condition as it serves as part of the cerebral venous drainage. She also had an adjacent cavernous malformation of the right frontal lobe that arose from the venous angioma. The patient sought neurosurgical consultation to determine the therapeutic options—surgery, gamma knife radiosurgery, or watchful waiting and anti-seizure medication. In the meantime, she has immersed herself in Google to learn all she can, since most primary care physicians have had little or no experience with these rare cerebral blood vessel malformations. After much research and consultations with several neurologists and neurosurgeons, she has taken the conservative medical and non-invasive route. She is doing well—armed with a final well-researched decision. She took charge of her health—and the decision she made, by personal education and consultations with several experts, is a well-researched decision that she is now comfortable living with. This is an optimal solution, better for the patient psychologically and comfortable for the attending physicians.
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.
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. Misconnection errors, resulting in wrong medication delivery to the wrong body site, have occurred. 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 and 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 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.
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:
