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CHIEF'S WORLD
           PATIENT FACT SHEET




                                                    20 Tips To Help Prevent
                                                    Medical Errors
A g e n c y f o r H e a l t h c a re R e s e a rc h a n d Q u a l i t y • 2 1 0 1 E a s t J e ff e r s o n S t re e t • R o c k v i l l e , M D 2 0 8 5 2


                                                    Medical errors are one of the Nation’s               on a salt-free diet is given a high-salt
                                                    leading causes of death and injury. A                meal.
                                                    recent report by the Institute of
                                                                                                         Most errors result from problems creat-
                                                    Medicine estimates that as many as
                                                                                                         ed by today’s complex health care sys-
                                                    44,000 to 98,000 people die in U.S.
                                                                                                         tem. But errors also happen when doc-
                                                    hospitals each year as the result of med-
                                                                                                         tors and their patients have problems
                                                    ical errors. This means that more peo-
         AHRQ is the lead agency charged with                                                            communicating. For example, a recent
                                                    ple die from medical errors than from
  supporting research designed to improve the                                                            study supported by the Agency for
                                                    motor vehicle accidents, breast cancer,
 quality of health care, reduce its cost, address                                                        Healthcare Research and Quality found
                                                    or AIDS.
          patient safety and medical errors, and
                                                                                                         that doctors often do not do enough to
                                                    Government agencies, purchasers of                   help their patients make informed deci-
   broaden access to essential services. AHRQ
                                                    group health care, and health care                   sions. Uninvolved and uninformed
 sponsors and conducts research that provides
                                                    providers are working together to make               patients are less likely to accept the doc-
evidence-based information on health care out-      the U.S. health care system safer for                tor’s choice of treatment and less likely
comes; quality; and cost, use, and access. The      patients and the public. This fact sheet             to do what they need to do to make the
information helps health care decisionmakers—       tells what you can do.                               treatment work.
  patients and clinicians, health system leaders,
                                                    What are Medical Errors?                             What Can You Do? Be Involved
      and policymakers—make more informed                                                                in Your Health Care
    decisions and improve the quality of health
                                                    Medical errors happen when something
                                                    that was planned as a part of medical                The single most important way you
                                  care services.
                                                    care doesn’t work out, or when the                   can help to prevent errors is to be an
                                                    wrong plan was used in the first place.              active member of your health care
                                                    Medical errors can occur anywhere in                 team. That means taking part in every
                                                    the health care system: in hospitals,                decision about your health care.
                                                    clinics, outpatient surgery centers, doc-            Research shows that patients who are
                                                    tors’ offices, nursing homes, pharma-                more involved with their care tend to
                                                    cies, and patients’ homes. Errors can                get better results.
                                                    involve medicines, surgery, diagnosis,
                                                                                                         Here are some specific tips, based on
                                                    equipment, or lab reports. They can
                                                                                                         the latest scientific evidence about what
                                                    happen during even the most routine
                                                                                                         works best:
          U.S. Department of Health                 tasks, such as when a hospital patient
                and Human Services
               Public Health Service
www.chiefsworld.tk
                                         Medicines                                   When you pick up your medicine
                                                                                     from the pharmacy, ask: Is this the
                                         Make sure that all of your doctors          medicine that my doctor prescribed?
                                         know about everything you are tak-          A study by the Massachusetts College
                                         ing. This includes prescription and         of Pharmacy and Allied Health Sciences
                                         over-the-counter medicines, and             found that 88 percent of medicine
                                         dietary supplements such as vitamins        errors involved the wrong drug or the
                                         and herbs. At least once a year, bring      wrong dose.
                                         all of your medicines and supplements
                                         with you to your doctor. “Brown bag-        If you have any questions about the
                                         ging” your medicines can help you and       directions on your medicine labels,
                                         your doctor talk about them and find        ask. Medicine labels can be hard to
                                         out if there are any problems. It can       understand. For example, ask if “four
                                         also help your doctor keep your records     doses daily” means taking a dose every
                                         up to date, which can help you get bet-     six hours around the clock or just dur-
                                         ter quality care.                           ing regular waking hours.
    Make sure that all of your doctors
                                         Make sure your doctor knows about           Ask your pharmacist for the best
       know about everything you are     any allergies and adverse reactions         device to measure your liquid medi-
                                         you have had to medicines. This can         cine. Also, ask questions if you’re not
    taking. This includes prescription
                                         help you avoid getting a medicine that      sure how to use it. Research shows that
     and over-the-counter medicines,     can harm you.                               many people do not understand the
                                                                                     right way to measure liquid medicines.
       and dietary supplements such      When your doctor writes you a pre-          For example, many use household tea-
              as vitamins and herbs.     scription, make sure you can read it.       spoons, which often do not hold a true
                                         If you can’t read your doctor’s handwrit-   teaspoon of liquid. Special devices, like
                                         ing, your pharmacist might not be able      marked syringes, help people to meas-
                                         to either.                                  ure the right dose. Being told how to
                                         Ask for information about your med-         use the devices helps even more.
                                         icines in terms you can understand–         Ask for written information about
                                         both when your medicines are pre-           the side effects your medicine could
                                         scribed and when you receive them:          cause. If you know what might happen,
                                         • What is the medicine for?                 you will be better prepared if it does–or,
                                                                                     if something unexpected happens
                                         • How am I supposed to take it, and         instead. That way, you can report the
                                           for how long?                             problem right away and get help before
                                         • What side effects are likely? What        it gets worse. A study found that writ-
                                           do I do if they occur?                    ten information about medicines can
                                                                                     help patients recognize problem side
                                         • Is this medicine safe to take with        effects and then give that information
                                           other medicines or dietary supple-        to their doctor or pharmacist.
                                           ments I am taking?
                                         • What food, drink, or activities
                                           should I avoid while taking this
                                           medicine?



2
CHIEF'S WORLD
  www.chiefsworld.tk
Hospital Stays                              urges its members to sign their initials
                                            directly on the site to be operated on
If you have a choice, choose a hospi-       before the surgery.
tal at which many patients have the
procedure or surgery you need.              Other Steps You Can Take
Research shows that patients tend to
                                            • Speak up if you have questions or
have better results when they are treated
                                              concerns. You have a right to ques-
in hospitals that have a great deal of
                                              tion anyone who is involved with
experience with their condition.
                                              your care.
If you are in a hospital, consider ask-
                                            • Make sure that someone, such as
ing all health care workers who have
                                              your personal doctor, is in charge
direct contact with you whether they
                                              of your care. This is especially
have washed their hands.
                                              important if you have many health
Handwashing is an important way to
                                              problems or are in a hospital.
prevent the spread of infections in hos-
pitals. Yet, it is not done regularly or    • Make sure that all health profes-
thoroughly enough. A recent study             sionals involved in your care have
found that when patients checked              important health information
whether health care workers washed            about you. Do not assume that
their hands, the workers washed their         everyone knows everything they
hands more often and used more soap.          need to.                                 If you are having surgery, make

When you are being discharged from          • Ask a family member or friend to         sure that you, your doctor, and your
the hospital, ask your doctor to              be there with you and to be your         surgeon all agree and are clear on
explain the treatment plan you will           advocate (someone who can help
use at home. This includes learning           get things done and speak up for         exactly what will be done.
about your medicines and finding out          you if you can’t). Even if you think
when you can get back to your regular         you don’t need help now, you might
activities. Research shows that at dis-       need it later.
charge time, doctors think their
                                            • Know that “more” is not always
patients understand more than they
                                              better. It is a good idea to find out
really do about what they should or
                                              why a test or treatment is needed
should not do when they return home.
                                              and how it can help you. You could
Surgery                                       be better off without it.

If you are having surgery, make sure        • If you have a test, don’t assume
that you, your doctor, and your sur-          that no news is good news. Ask
geon all agree and are clear on exact-        about the results.
ly what will be done. Doing surgery at
                                            • Learn about your condition and
the wrong site (for example, operating
                                              treatments by asking your doctor
on the left knee instead of the right) is
                                              and nurse and by using other reli-
rare. But even once is too often. The
                                              able sources. For example, treat-
good news is that wrong-site surgery is
                                              ment recommendations based on
100 percent preventable. The American
                                              the latest scientific evidence are
Academy of Orthopaedic Surgeons
                                              available from the National


                                                                                                                            3
www.chiefsforum.tk
                       www.chiefsforum.tk
                 Guideline Clearinghouse at
                 (www.guideline.gov). Ask your doc-
                 tor if your treatment is based on the
                 latest evidence.
              For more information about medical
              errors, see AHRQ’s Web site at
              http://www.ahrq.gov/errors.htm. Or
              call the AHRQ Clearinghouse at 1-800-
              358-9295 for a Federal report on med-
              ical errors (Pub. No. OM00-0004).



    VISIT OUR FORUM FOR REPORTS ON HEALTH,STOCKMARKET AND BULLION


         www.chiefsforum.tk




                                                         AHRQ Pub. No. 00-P038
                                                               September 2000


4

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Medical error tips

  • 1. CHIEF'S WORLD PATIENT FACT SHEET 20 Tips To Help Prevent Medical Errors A g e n c y f o r H e a l t h c a re R e s e a rc h a n d Q u a l i t y • 2 1 0 1 E a s t J e ff e r s o n S t re e t • R o c k v i l l e , M D 2 0 8 5 2 Medical errors are one of the Nation’s on a salt-free diet is given a high-salt leading causes of death and injury. A meal. recent report by the Institute of Most errors result from problems creat- Medicine estimates that as many as ed by today’s complex health care sys- 44,000 to 98,000 people die in U.S. tem. But errors also happen when doc- hospitals each year as the result of med- tors and their patients have problems ical errors. This means that more peo- AHRQ is the lead agency charged with communicating. For example, a recent ple die from medical errors than from supporting research designed to improve the study supported by the Agency for motor vehicle accidents, breast cancer, quality of health care, reduce its cost, address Healthcare Research and Quality found or AIDS. patient safety and medical errors, and that doctors often do not do enough to Government agencies, purchasers of help their patients make informed deci- broaden access to essential services. AHRQ group health care, and health care sions. Uninvolved and uninformed sponsors and conducts research that provides providers are working together to make patients are less likely to accept the doc- evidence-based information on health care out- the U.S. health care system safer for tor’s choice of treatment and less likely comes; quality; and cost, use, and access. The patients and the public. This fact sheet to do what they need to do to make the information helps health care decisionmakers— tells what you can do. treatment work. patients and clinicians, health system leaders, What are Medical Errors? What Can You Do? Be Involved and policymakers—make more informed in Your Health Care decisions and improve the quality of health Medical errors happen when something that was planned as a part of medical The single most important way you care services. care doesn’t work out, or when the can help to prevent errors is to be an wrong plan was used in the first place. active member of your health care Medical errors can occur anywhere in team. That means taking part in every the health care system: in hospitals, decision about your health care. clinics, outpatient surgery centers, doc- Research shows that patients who are tors’ offices, nursing homes, pharma- more involved with their care tend to cies, and patients’ homes. Errors can get better results. involve medicines, surgery, diagnosis, Here are some specific tips, based on equipment, or lab reports. They can the latest scientific evidence about what happen during even the most routine works best: U.S. Department of Health tasks, such as when a hospital patient and Human Services Public Health Service
  • 2. www.chiefsworld.tk Medicines When you pick up your medicine from the pharmacy, ask: Is this the Make sure that all of your doctors medicine that my doctor prescribed? know about everything you are tak- A study by the Massachusetts College ing. This includes prescription and of Pharmacy and Allied Health Sciences over-the-counter medicines, and found that 88 percent of medicine dietary supplements such as vitamins errors involved the wrong drug or the and herbs. At least once a year, bring wrong dose. all of your medicines and supplements with you to your doctor. “Brown bag- If you have any questions about the ging” your medicines can help you and directions on your medicine labels, your doctor talk about them and find ask. Medicine labels can be hard to out if there are any problems. It can understand. For example, ask if “four also help your doctor keep your records doses daily” means taking a dose every up to date, which can help you get bet- six hours around the clock or just dur- ter quality care. ing regular waking hours. Make sure that all of your doctors Make sure your doctor knows about Ask your pharmacist for the best know about everything you are any allergies and adverse reactions device to measure your liquid medi- you have had to medicines. This can cine. Also, ask questions if you’re not taking. This includes prescription help you avoid getting a medicine that sure how to use it. Research shows that and over-the-counter medicines, can harm you. many people do not understand the right way to measure liquid medicines. and dietary supplements such When your doctor writes you a pre- For example, many use household tea- as vitamins and herbs. scription, make sure you can read it. spoons, which often do not hold a true If you can’t read your doctor’s handwrit- teaspoon of liquid. Special devices, like ing, your pharmacist might not be able marked syringes, help people to meas- to either. ure the right dose. Being told how to Ask for information about your med- use the devices helps even more. icines in terms you can understand– Ask for written information about both when your medicines are pre- the side effects your medicine could scribed and when you receive them: cause. If you know what might happen, • What is the medicine for? you will be better prepared if it does–or, if something unexpected happens • How am I supposed to take it, and instead. That way, you can report the for how long? problem right away and get help before • What side effects are likely? What it gets worse. A study found that writ- do I do if they occur? ten information about medicines can help patients recognize problem side • Is this medicine safe to take with effects and then give that information other medicines or dietary supple- to their doctor or pharmacist. ments I am taking? • What food, drink, or activities should I avoid while taking this medicine? 2
  • 3. CHIEF'S WORLD www.chiefsworld.tk Hospital Stays urges its members to sign their initials directly on the site to be operated on If you have a choice, choose a hospi- before the surgery. tal at which many patients have the procedure or surgery you need. Other Steps You Can Take Research shows that patients tend to • Speak up if you have questions or have better results when they are treated concerns. You have a right to ques- in hospitals that have a great deal of tion anyone who is involved with experience with their condition. your care. If you are in a hospital, consider ask- • Make sure that someone, such as ing all health care workers who have your personal doctor, is in charge direct contact with you whether they of your care. This is especially have washed their hands. important if you have many health Handwashing is an important way to problems or are in a hospital. prevent the spread of infections in hos- pitals. Yet, it is not done regularly or • Make sure that all health profes- thoroughly enough. A recent study sionals involved in your care have found that when patients checked important health information whether health care workers washed about you. Do not assume that their hands, the workers washed their everyone knows everything they hands more often and used more soap. need to. If you are having surgery, make When you are being discharged from • Ask a family member or friend to sure that you, your doctor, and your the hospital, ask your doctor to be there with you and to be your surgeon all agree and are clear on explain the treatment plan you will advocate (someone who can help use at home. This includes learning get things done and speak up for exactly what will be done. about your medicines and finding out you if you can’t). Even if you think when you can get back to your regular you don’t need help now, you might activities. Research shows that at dis- need it later. charge time, doctors think their • Know that “more” is not always patients understand more than they better. It is a good idea to find out really do about what they should or why a test or treatment is needed should not do when they return home. and how it can help you. You could Surgery be better off without it. If you are having surgery, make sure • If you have a test, don’t assume that you, your doctor, and your sur- that no news is good news. Ask geon all agree and are clear on exact- about the results. ly what will be done. Doing surgery at • Learn about your condition and the wrong site (for example, operating treatments by asking your doctor on the left knee instead of the right) is and nurse and by using other reli- rare. But even once is too often. The able sources. For example, treat- good news is that wrong-site surgery is ment recommendations based on 100 percent preventable. The American the latest scientific evidence are Academy of Orthopaedic Surgeons available from the National 3
  • 4. www.chiefsforum.tk www.chiefsforum.tk Guideline Clearinghouse at (www.guideline.gov). Ask your doc- tor if your treatment is based on the latest evidence. For more information about medical errors, see AHRQ’s Web site at http://www.ahrq.gov/errors.htm. Or call the AHRQ Clearinghouse at 1-800- 358-9295 for a Federal report on med- ical errors (Pub. No. OM00-0004). VISIT OUR FORUM FOR REPORTS ON HEALTH,STOCKMARKET AND BULLION www.chiefsforum.tk AHRQ Pub. No. 00-P038 September 2000 4