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Medical & Nursing Errors In The Hospital Setting
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Medical & Nursing Errors In The Hospital Setting

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This presentation is designed to shed light on the ever increasing epidemic of medical errors from hospitals and healthcare providers.

This presentation is designed to shed light on the ever increasing epidemic of medical errors from hospitals and healthcare providers.

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Medical & Nursing Errors In The Hospital Setting Medical & Nursing Errors In The Hospital Setting Presentation Transcript

  • MEDICAL & NURSING ERRORS IN THE HOSPITAL SETTING By Paul Parks-RN, LNC-Research Expert “integrating medicine and law” © PMLC 2012
  • MEDICAL | HOSPITAL ERRORS ARE A MAJOR PUBLIC HEALTH PROBLEM  Factors related to patient harm :  First is the type of treatment received.  Studies have shown that patients receiving high risk procedures in intensive care are more at risk than those receiving low risk procedures in an outpatient treatment setting.  The risk increases with:  1. Complexity of treatment.  2. Length of stay.  3. Use of internal devices that breach normal defense mechanisms.
  • Factors related to patient harm: Risk is also a part of the Hospital “experience” due to the organizational set-up of health services. For example, high bed occupancy increases the movement of patients and the tendency of hospitals to admit patients from a wide geographical range can further heighten the risk associated with medical treatment.
  • OVERVIEW OF HOSPITAL RISK FACTORS Type of treatment received. Whatever the issue might be that brought you to the hospital, you can count on the fact that you will also face multiple health hazards during your stay. As a patient, you will probably never be told of these risks, so it is important to be informed before your hospital visit. This is how you become an informed and empowered patient. A little research and knowledge goes a long way in making your stay as risk free as possible !
  • OTHER HOSPITAL FACTORS IN PATIENT HARM Patient harm occurs when local standards of care fall short of those of desired evidence-based practice. Therefore, patient safety is an issue for those involved in the management and organization of the health care delivery. Certain aspects of the delivery of health care can hamper efforts to maintain standards and reduce patient harm: These include:
  • SUB-OPTIMAL STANDARDS OF CARE IN HOSPITAL SETTINGS Lack of explicit controls that allows a culture of blame to proliferate. Insufficient investment in systems redesign leading to potentially unsafe systems by virtue of them being outdated and or poorly maintained. Lack of the appropriate equipment and supplies, insufficient time and inadequate supervision , this happens even in the BEST teaching facilities. Names mean nothing!
  • SUB-OPTIMAL STANDARDS OF CARE IN HOSPITAL SETTINGS Inability to afford information technology due to high costs and privacy concerns. Lack of the appropriate technical expertise through the absence of a continuous training environment. Poor interpersonal communication with no effective interaction between patients and staff, as well as between health professionals, leading to communication failures.
  • FACTS & STATISTICS ON PATIENT HARM Under-reporting of Iatrogenic events is a FACT. Many “events” go unreported, some are covered up in order to keep the hospitals reputation favorable in the community. As a matter of fact, as few as 5% and only up to 20% of Iatrogenic acts are ever reported. This implies that if medical errors were completely and accurately reported, we would have a much higher annual Iatrogenic death rate of the reported 200,000+ a year. An Iatrogenic event is defined as: When a patient acquires a new illness, or is injured by the services provided by a medical provider, then the result is considered to be "iatrogenic". Iatrogenic events may result during diagnosis or treatment, and they may be physical, mental or emotional problems.
  • EXAMPLES OF IATROGENECIC EVENTS A few examples of “iatrogenesis” would be when a patient becomes infected because a doctor or nurse didnt wash his/her hands after touching a previous patient. A surgical mistake, such as nicking an artery with a surgical instrument, or removing the wrong body part or replacing the wrong knee would also be considered iatrogenic. Drug conflicts that are documented, but unknown to the prescriber are iatrogenic. Even psychological therapies, if they result in further psychoses or neuroses for the patient, would be considered iatrogenic.
  • STATISTICS ON MEDICAL ERRORS In one decade 10 years, the deaths caused by conventional medicine are approximately 8 million. This is more than all the casualties from all the wars America has ever fought in. The total number of medical errors and deaths every 10 years equals SIX jumbo jets crashing every day ! Medical errors are one of the Nations leading causes of death and injury. A recent report by the Institute of Medicine estimates that as many as 44,000 to 98,000 people die in U.S. hospitals each year as the result of medical errors. This means that more people die from medical errors than from motor vehicle accidents, breast cancer, or AIDS.
  • THE IMPACT OF MEDICAL ERRORS The latest Institute of Medicine IOM study found that medication errors are among the most common medical mistakes, harming at least 1.5 million people every year. According to the study, 400,000 preventable drug-related injuries occur each year in hospitals, 800,000 in long-term care settings, and roughly 530,000 among Medicare recipients in outpatient clinics .
  • ERROR EXAMPLES Misdiagnosis of an illness, failure to diagnose or delay of a diagnosis. This type of error could be a direct mistake of a doctor or caused when the doctor is acting on incorrect information supplied by some other person. Giving the wrong drug or (wrong patient, wrong chemical, wrong dose, wrong time, wrong route). Giving two or more drugs that interact unfavorably or cause poisonous metabolic byproducts. Wrong-site surgery, such as amputating the wrong limb. Retained surgical instruments. In particular, gossypiboma, resulting from a surgical sponge being left behind inside the patient after surgery.
  • ERROR EXAMPLES Patients implementation of drugs and treatments. Using race as a diagnosis, not a factor. Transplanting organs of the wrong blood type. Incorrect record keeping. Common Excuses Given: "Why disclose the error? The patient was going to die anyway.“ "Telling the family about the error will only make them feel worse.“ "It was the patients fault. If he wasnt so (obese, sick, etc.), this error wouldnt have caused so much harm.“ "Well, we did our best. These things happen.“ "If were not totally and absolutely certain the error caused the harm, we dont have to tell."
  • 1 in 3 Patients Harmed During Hospital Stays A study, in Aprils Health Affairs, reflects two reports issued in November 2010 that showed rates of adverse events hovering near 25% among hospitalized Medicare patients nationwide . A survey released in [2010] March 31, revealed patients are scared of medical mishaps. Nearly 60% of adults polled by the Consumer Reports National Research Center believe medical errors are common in hospitals, and nearly half said serious harm is common. Nearly 80% of patients said they feared contracting an infection in a hospital, 71% were worried about medication errors and 65% were scared of surgical mistakes, and with good reason. Consider the following real life stories.
  • The Sixth Biggest Killer in America Researchers at the Harvard School of Medicine have found that even today, about 18 percent of patients in hospitals are injured during the course of their care and that many of those injuries are life-threatening, or even fatal. The Office of the Inspector General of the U.S. Department of Health and Human Services found that one in seven Medicare patients are injured during hospital stays and that adverse events during the course of care contribute to the deaths of 180,000 patients every year. Since the IOM first shined a light on the dismal state of patient safety in American hospitals, an IOM seminal study of preventable medical errors estimated the cost of dying to be $29 billion annually! If the Centers for Disease Control were to include preventable medical errors as a category, these conclusions would make it the sixth leading cause of death in America. This is totally unacceptable and must be changed.
  • NEVER EVENTS: NEVER SAY NEVER A “Never” event is an inexcusable outcome in a health care setting. The initial list of 28 events was compiled by the National Quality Forum of the United States. They are defined as "adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability." Even errors that the government and private health insurers have classified as “never events,” events that should never happen in a hospital, are occurring at alarming rates. Recently the Joint Commission Center on Transforming Healthcare reported that as many as 40 wrong site, wrong side and wrong patient procedures happen every week in the U.S. Similarly, researchers in Colorado recently found that surgical “never” events, such as operating on the wrong patient or wrong site or performing the wrong procedure, are occurring all too frequently
  • THE 27 “NEVER EVENTS” LIST Surgery on the wrong body part. Surgery on the wrong patient. Wrong surgical procedure performed on a patient. Object left in patient after surgery. Death of a patient, who had been generally healthy, during or immediately after surgery for a localized problem. Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics. Patient death or serious disability associated with the misuse or malfunction of a device. Patient death or serious disability associated with intravascular air embolism. Infant discharged to the wrong person. Patient death or serious disability associated with patient disappearing for more than four hours.
  • 27 “NEVER EVENTS” Patient suicide or attempted suicide resulting in serious disability. Patient death or serious disability associated with a medication error. Patient death or serious disability associated with transfusion of blood or blood products of the wrong type. Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy. Patient death or serious disability associated with the onset of hypoglycemia, a drop in blood sugar. Death or serious disability associated with failure to identify and treat hyperbilirubinemia, a blood abnormality, in newborns.
  • 27 “NEVER EVENTS” Severe pressure ulcers acquired in the hospital- [as photo below.] Patient death or serious disability due to spinal manipulative therapy. Patient death or serious disability associated with an electric shock. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances. Patient death or serious disability associated with a burn incurred in the hospital.
  • 27 “NEVER EVENTS” Patient death associated with a fall suffered in the hospital. Patient death or serious disability associated with the use of restraints or bedrails. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider. Abduction of a patient. Sexual assault on a patient. Death or significant injury of a patient or staff member resulting from a physical assault in the hospital.
  • STORIES OF HARM & DEATH FROM MEDICAL ERRORS  Brother bleeds to death from central line medical error: On June 2011, Mr. C’s brother died as a result of a mistake made by 2 anesthesiologists at a hospital. While central lines were being placed into his internal jugular vein to prepare for a liver transplant, the catheter/needle was advanced too far, perforating both the jugular and right subclavian artery. The brother bled to death. Although these doctors admit to making a terrible mistake, they are not being held accountable in any way. The hospital offered to pay his Mother $18,000.00, but only in exchange for her not to pursue complaints on the hospital or any of the physician’s involved.
  • SURGICAL ERROR DURING BIOPSY CAUSES PATIENT TO BE BLIND A simple forceps biopsy was performed in order to to diagnose and grade a chest tumor. A surgical accident occurred during this biopsy; the Superior Vena Cava ( the large vein which returns blood to the heart from the head, neck and both upper limbs) was erroneously cut and erroneously sewn closed, resulting in Superior Vena Cava arrest. Surgery was emergently ended. During recovery, while the patient was on a ventilator, he awoke and realized he was totally blind. All from a simple chest biopsy.
  • Misdiagnosed with Aggressive Cancer This patient was misdiagnosed. She was told she had an aggressive, deadly cancer, and had six months to live unless she received the necessary chemotherapy to buy herself one extra year. Despite resistance from her oncologist, she was able to prove she had no cancer at all. Almost five years later she had never had treatment. It took three months from the original biopsy that instigated the error until word from the NIH came that she was correct and had no malignancy. She had to fight the system of doctors who did not want to admit their error. She had no medical training or healthcare background. Today she advocates for others through a number of writing, speaking, broadcasting activities.
  • Holding Doctors & Nurses Accountable Consistent with what patients say they would expect after a medical error, studies of patients who file suit find litigants are motivated to find out what happened and to prevent future injury, motivations that implicate apologies. Surveyed medical malpractice claimants about the reasons they filed suit, over 90% of respondents indicated they wanted to prevent the same thing from happening to someone else, to receive an explanation for what had happened, or for the doctors to realize what they had done. Of the respondents who thought something could have been done to prevent the lawsuit, approximately 40% reported that if they had received an explanation and apology, they would not have felt the need to file suit. This should clue doctors, nurses and hospitals to be more transparent about admitting errors, sadly as of yet they do not.
  • Nursing Mistakes Kill & Injure Thousands  Cost-cutting exacts toll on patients, hospital staffs: Overwhelmed and inadequately trained nurses kill and injure thousands of patients every year as hospitals sacrifice safety for an improved bottom line, a Tribune investigation has found.  Since 1995, at least 1,720 hospital patients have been accidentally killed and 9,584 others injured from the actions or inaction of registered nurses across the country, who have seen their daily routine radically altered by cuts in staff and other belt- tightening in U.S. hospitals.
  • Medical Paradigm in the Following StatisticsThese estimates of death due to error are lower than those in arecent IOM report. If the higher estimates are used, the deaths dueto iatrogenic causes would range from 230,000 to 284,000. Evenat the lower estimate of 225,000 deaths per year, this constitutesthe third leading cause of death in the U.S. NOT sixth.
  • DEATHS FROM MEDICAL ERRORS
  • GOING TO THE HOSPITAL: WHAT YOU NEED TO KNOW
  • When Patients File Complaints Now Under Consideration In The Senate. Patients who file complaints against doctors and other health care providers would be able to find out more information about the status of their complaints and how they are handled under a bill now being debated by state lawmakers. HB 1493 would improve the process for holding doctors and other health care workers accountable for unprofessional conduct and unsafe care, according to Consumers Union, the nonprofit publisher of Consumer Reports. The bill was approved by a 68 to 29 vote in the House and has been sent to the Senate for consideration.
  • Bill Would Create More Transparency Under the proposed bill, patients who file complaints will have the opportunity to submit an impact statement detailing how they were affected by the doctor’s or health care worker’s conduct. The bill requires the agency handling the complaint to respond promptly to any inquiries regarding the status of the case. The person who filed the complaint and the person who is the subject of the complaint may request a complete copy of the file on the matter with some exceptions of confidential information.
  • More Transparency Once a complaint has been reviewed, the disciplining body must inform the person who filed it of the results of its evaluation. If the complaint is settled before an impact statement has been filed, the patient must be given the chance to submit one and make a request for reconsideration. The doctor or health care worker will be allowed to respond to the amended complaint. Once the matter has been fully considered, the agency must issue a written report that provides an explanation for its decision.
  • CONCLUSIONS Despite the shocking number of medical errors, few injured patients ever file a medical negligence lawsuit, and fewer still file frivolous claims. Research shows almost all medical negligence claims are meritorious. Claims where there was no error are rarely paid and researchers have concluded the reverse – errors which are never compensated – is a far bigger problem. The reality is, an epidemic of medical malpractice, NOT of malpractice lawsuits. The rising cost of health care intensifies the need to focus on preventable medical errors and their huge associated costs. The savings from preventing medical errors run into billions of dollars. The savings from restricting patients’ access to justice, however, are negligible.
  • Civil Justice Keeps Us Safer In conclusion ,every profession has its bad apples and doctors, nurses and hospitals are no exception. With that said, only six percent of doctors are responsible for nearly 60% of all medical negligence, and the civil justice system is the only effective means for holding them accountable. No apologies for a wrongful death or putting a “cap” on a loved ones life. Other disciplinary mechanisms are completely inadequate. Most “bad apples” just move to a different State. They know how to play the game leaving the patient and family clueless , thus seeking legal council is the most prudent action. For example, State medical boards, for instance, are supposed to discipline doctors who consistently violate standards of care. Yet two-thirds of doctors who make 10 or more medical negligence payments are never disciplined at all, this is why we need the legal system as the medical boards hardly slap the wrist.
  • SAFETY WITH ACCOUNTABILITY Hospitals are on the front lines of patient safety, yet nearly half of all U.S. hospitals have never reported a disciplinary action to the National Practitioner Databank since its creation in 1990. Alternative compensation systems, such as health courts, propose eliminating or greatly sidelining disciplinary systems altogether. The civil justice system holds doctors, nurses, hospitals and insurance companies accountable. It is this accountability that drives the development of patient safety systems that help prevent negligence before it occurs. Hospitals, health systems and even entire medical fields have reformed dangerous practices because of the civil justice system. Without the accountability the civil justice system enforces, patient safety will suffer and health care costs will go up for everyone.
  • Not All Errors Occur in Hospitals An office-based physician who does not order the correct medication, fails to follow up on a test result or has insufficient communication with a referring doctor can cause just as much harm to a patient, if not more. Errors of omission can be just as bad as errors of commission, even if they are harder to spot.
  • One Last Note About Errors Until tangible transparent solutions are made available, the unacceptable status quo of medical and medication errors will persist despite best efforts. In this case, knowledge is power ! Patient empowerment through education is key. In this day and age, the consumer/patient MUST take control over their own healthcare choices, if they do not; then they are left at the mercy of the hospital and healthcare providers. Know your rights as a patient and don’t be fooled by bad apples and stooges!
  • THE END This has been a Parks Medical-Legal Presentation “integrating medicine & law “ ™Web: http:www.parksmedicallegal.comBlog: http://parksmedicallegal.blogspot.com©2012 Parks Medical-Legal Consulting & Research