This presentation is about how safe is healthcare?
This is a documentary that explores patient safety and the types of problems that can contribute to adverse outcomes.
There have been many studies looking at patient safety and medical errors, but there have been two major studies that have looked at the overall problem. The first was performed on chart review of 30,000 discharges from hospitals in NY State in 1984. The second looked at 15,000 discharges from hospitals in Utah and Colorado in 1992. The rate of preventable adverse events, or medical error rate, was similar in the two studies: 2.1% and 1.5% respectively. The percentage of the adverse events that contributed to the death of the patient was slightly higher in the NY study, at 13.6%, than the Utah and Colorado study, at 8.8%.
The Institute of Medicine released a report that summarized many studies regarding medical errors and the impact on the health care system. In reviewing these two studies, the error and death rate were extrapolated to the number of admissions to all of the hospitals in the US.
The conclusion was that medical errors contributed to the death of between 44,000 and 98,000 people annually.
These same studies looked at what types of medical errors occurred. Medical errors can be divided into errors related to diagnosis, treatment, or preventive care. Diagnostic errors can be related to making an incorrect diagnosis, the failure to perform an appropriate test, or the failure to respond to the result of a test. Treatment errors can be due to technical errors in performing a procedure, including surgery and anesthesia, medication errors, a delay in treatment, or the provision of care that is inappropriate or not indicated for the clinical situation. Errors related to preventive care include failure to provide preventive treatment or the failure to monitor the progress of the patient. In specific cases, it is possible that the medical error may involve more than one type of error
The patient was a 50 year old black male admitted for spinal fusion. When aroused from anesthesia, he was found to have paraplegia which did not improve overnight. The surgeon consulted a Neurologist and ordered an MRI of the spinal cord. The patient was diagnosed with transverse myelitis (inflammation of the spinal cord). The patient was not improving and requested transfer to the regional American hospital. At the American hospital, the patient was examined and the MRI reviewed and a diagnosis of an acute spinal cord cerebrovascular accident (stroke) was made. A repeat MRI confirmed progressive changes associated with the cerebrovascular accident.
The patient was a 72 year old white female admitted with a urinary tract infection. She was admitted and started on antibiotics. On the next day, she was worse, with worsening fever and lower blood pressure. She was found to be septic and was transferred to the ICU. The covering physician started several stronger antibiotics, including gentamicin, but did not order any drug levels. One week later, the patient had reduced urine output and was found to have acute renal failure. Chart review indicated that a failure to check drug levels lead to the development of acute renal failure.
The patient was a 45 year old white male admitted for a laparoscopic Nissan fundoplication. Post-operatively, the patient has difficulty resuming diet with pain and nausea. Chest x-ray showed free air under the diaphragm, as well as pneumomediastinum and subcutaneous emphysema. The patient was discharged with medicines for relief of pain and nausea. The patient returned three days later with chest pain, fever, and inability to swallow. CT scan showed mediastinitis. The patient was taken to surgery where a laceration of the esophagus was found.
The patient was a 56 year old white male admitted for inguinal hernia repair. In the operating room, a right inguinal herniorrhaphy was performed without difficulty. Upon awakening, patient says that the problem that he was having was on the left side. Physical examination confirmed that the patient had a left inguinal hernia and it was determine that surgery was done on the wrong side.
The patient was a 40 year old white male brought to the emergency room in cardiac arrest. The patient was successfully resuscitated and the staff started preparations for transfer to the ICU. The patient required intubation, but the tube was accidentally placed in the esophagus. The patient was receiving no ventilatory support and the error was not recognized until the patient arrested again. The patient was resuscitated again, the tube removed and placed correctly. Review of the chart demonstrated that the error in intubation lead to the second cardiac arrest.
The patient was a 56 year old white female who presented to the emergency room with atypical chest pain. The emergency room was busy, so there was a wait for the patient to be placed in a room, a delay in being seen by the physician, and a delay in getting an EKG. The EKG showed the patient to have an acute myocardial infarction. Once the EKG was done, appropriate care was started, but there was a delay in the appropriate care.
Patient was a 24 year ole white female seen in the office for nasal congestion. The patient was diagnosed with an upper respiratory infection and prescribed amoxicillin. Later that day, she developed sudden shortness of breath and presented to the hospital. In the emergency room, she was diagnosed with an anaphylactic reaction. On chart review, it was determined that there was no indication for the amoxicillin and that the allergic reaction was avoidable had the antibiotic not been prescribed.
TD is a 70 year old white female admitted for routine hip replacement. There was no problem in performing the surgery and the patient was doing well for the initial post-operative period. However, on the third post-operative day, the patient started having severe shortness of breath. An arterial blood gas showed that there was significant hypoxia. A CT scan showed multiple pulmonary emboli. On chart review, it was identified that the patient did not receive appropriate venous thromboembolism prophylaxis.
The patient was a 76 year old black female admitted with a hip fracture and found to have atrial fibrillation with a rapid ventricular response. She was started on several medicines to slow the heart, then had repair of the hip fracture without difficulty. Post-operatively, she did well and was transferred to the rehabilitation floor. Nurses did not monitor the heart rate. After three days, the patient had a syncopal episode. She was found to have profound bradycardia, which improved after adjustment of the dose of the medicines.
In conclusion, medical errors within our health care system are common and the types of medical vary significantly, depending upon the clinical circumstances. It is only with a better understanding of the frequency and nature of medical errors that improvement can be made in preventing medical errors and improving patient safety.
Final project presentation health language
HOW SAFE IS HEALTHCARE DOCUMENTARY
HCA/220 - THE LANGUAGE OF HEALTH CARE
INSTRUCTOR: JUDY JEAN
DECEMBER 16, 2013
PREVENTABLE ADVERSE OUTCOMES ARE
COMMON IN HEALTH CARE
THERE WERE TWO LARGE SEMINAL
NY STATE IN 1984
COLORADO AND UTAH IN 1992
PREVENTABLE ADVERSE EVENT RATE
% THAT CONTRIBUTED TO DEATH
Types of medical errors:
Error or delay in diagnosis
Failure to use appropriate test
Failure to respond to result of test
Procedural technical error
Delay in treatment
Failure to provide preventive treatment
Failure to monitor patient
BETTER UNDERSTAND THE TYPES OF
ERRORS HERE IS AN EXAMPLES OF THE
COMMON TYPES OF ERRORS
ERROR IN DIAGNOSIS
50 YR. BM ADM FOR SPINE FUSION
AWOKE FROM SURGERY WITH
DX TRANSVERSE MYELITIS
TRANSFERRED TO AMERICAN
CUTE SPINAL CORD CVA
FAILURE TO USE APPROPRIATE TEST
72 YR. WF WITH UTI
ON THE NEXT DAY, SHE BECAME SUDDENLY WORSE
TRANSFERRED TO ICU
COVERING DOCTOR CHANGED ANTIBIOTICS
DID NOT ORDER LEVELS
ONE WEEK LATER SHE HAD ACUTE RENAL FAILURE
CHART REVIEW - FAILURE TO CHECK LEVEL
FAILURE TO RESPOND TO RESULT OF A TEST
45 YR. WM ADM FOR LAP NISSAN FUNDOPLICATION
POST-OP, HAD DIFFICULTY RESUMING DIET
CXR SHOWED FREE AIR UNDER DIAPHRAGM, PNEUMOMEDIASTINUM
PT. DISCHARGED WITH MEDICINES FOR PAIN AND NAUSEA
RETURNED THREE DAYS LATER WITH MEDIASTINITIS
FOUND TO HAVE ESOPHAGEAL LACERATION ON SURGERY
PROCEDURAL TECHNICAL ERROR OPERATION
PROCEDURAL TECHNICAL ERROR - OPERATION
56 YR. WM ADM FOR HERNIA REPAIR
DURING SURGERY, RIGHT INGUINAL HERNIORRHAPHY PERFORMED
UPON AWAKENING, PATIENT SAYS THAT LEFT HERNIA WAS PROBLEM
UPON REVIEW, IT WAS DETERMINED THAT SURGERY WAS DONE ON WRONG SIDE.
PROCEDURAL TECHNICAL ERROR - OTHER
40 YR. WM BROUGHT TO THE ER IN CARDIAC ARREST
PT. RESUSCITATED, THEN REQUIRED INTUBATION
THE INTUBATION WAS PLACED IN ESOPHAGUS
PT. DETERIORATED AND REQUIRED REPEAT RESUSCITATION
CHART REVIEW SHOWED THAT THE ERROR WAS THE CAUSE OF THE SECOND ARREST
DELAY IN TREATMENT
56 YR. WF WITH ATYPICAL CHEST PAIN
ER WAS BUSY, SO SLOW TO GET INTO ROOM
MD DID NOT SEE IMMEDIATELY
EKG SHOWED ACUTE MI
THERE WAS DELAY IN PROVIDING THROMBOLYTIC
24 YR. WF SEEN FOR NASAL CONGESTION
DX AS UPPER RESPIRATORY INFECTION
RX AMOXICILLIN FOR THE URI
LATER THAT DAY, HAD SHORTNESS OF BREATH
IN ER, FOUND TO HAVE ANAPHYLACTIC REACTION
CHART REVIEW SHOWED UNNECESSARY ANTIBIOTICS LEAD TO REACTION
FAILURE TO PROVIDE PREVENTIVE CARE
TD IS A 70 YR. WF FOR HIP REPLACEMENT
THE SURGERY WAS UNEVENTFUL
3 DAYS POST-OPERATIVELY, SHE DEVELOPED SHORTNESS OF
ABG SHOWED SIGNIFICANT HYPOXIA
CT SCAN SHOWS PULMONARY EMBOLI
CHART REVIEW - NO VTE PROPHYLAXIS
FAILURE TO MONITOR PATIENT
FAILURE TO MONITOR PATIENT
76 YR. BF ADM WITH HIP FRACTURE AND ATRIAL FIBRILLATION
STARTED ON SEVERAL MEDICINES TO SLOW THE HEART
HIP FRACTURE REPAIRED WITHOUT DIFFICULTY
IMPROVED AND TRANSFERRED TO REHAB FLOOR
NURSES DID NOT MONITOR HEART RATE
AFTER THREE DAYS, SHE HAS SYNCOPE
FOUND TO HAVE PROFOUND BRADYCARDIA
MEDICAL ERRORS ARE BOTH
UNDERSTANDING IS NECESSARY FOR IMPROVEMENT
1BRENNAN, T.A., LEAPE, L.L., LAIRD, N.M., ET. AL., "INCIDENCE OF ADVERSE EVENTS AND
NEGLIGENCE IN HOSPITALIZED PATIENTS. RESULTS OF THE HARVARD MEDICAL PRACTICE
STUDY I", NEJM 324 (1991), PP 370-376.
2LEAPE, L.L., BRENNAN, T.A., LAIRD, N.M., ET. AL., "THE NATURE OF ADVERSE EVENTS IN
HOSPITALIZED PATIENTS. RESULTS OF THE HARVARD MEDICAL PRACTICE STUDY II", NEJM 324
(1991), PP 377-384.
3THOMAS, E.J. STUDDERT, D.M., BURSTIN, H.R., ET. AL., "INCIDENCE AND TYPES OF ADVERSE
EVENTS AND NEGLIGENT CARE IN UTAH AND COLORADO," MEDICAL CARE 38 (2000), PP. 261-271.
4KOHN, L., CORRIGAN, J.M., DONALDSON, M.S., EDS, TO ERR IS HUMAN: BUILDING A SAFER
HEALTH SYSTEM. WASHINGTON, D.C.: COMMITTEE ON QUALITY ON HEALTH CARE IN AMERICA,
INSTITUTE OF MEDICINE. NATIONAL ACADEMY PRESS, 2000