October 2003 Food For Thought
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IN THIS ISSUE: Medical Errors

"It is no use to say, "˜We are doing our best.'
You have got to succeed in doing what is necessary."�
" Winston Churchill

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Medical Errors
Prevention is Key

Making mistakes on the job is commonplace.
However, for healthcare workers the consequences
of a mishap prove to be more serious than perhaps
in any other profession. Consider this" the National
Academies' Institute of Medicine reports that
approximately 50-100,000 Americans die each year
from medical errors, making it the eighth leading
cause of death. Furthermore, it's estimated that
$17 to 38 billion is spent yearly on repeat tests,
disability, and death due to error.

Unfortunately, the issue of medical errors is nothing
new. While many may think of these errors occurring
mainly hospital settings, the fact is that no facility is
immune" long term care facilities, doctors' offices,
urgent care centers, pharmacies and home care all face
this issue.

While the statistics don't give much reason to be
hopeful, there is actually some good news. Research
has shown that most medical errors can be prevented.

The Joint Commission on Accreditation of Healthcare
Organizations (JACHO) has created a set of evidence-
based recommendations to help organizations reduce
medical errors.
These recommendations include:
1. Improve the accuracy of patient identification.
2. Improve the effectiveness of communication among
caregivers.
3. Improve the safety of using high-alert medications.
4. Eliminate wrong-site, wrong-patient and wrong-
procedure surgery.
5. Improve the safety of using infusion pumps.
6. Improve the effectiveness of clinical alarm systems.
You can familiarize yourself with all the JCAHO patient
safety requirements at www.JCAHO.org.

In addition, experts have devised a proactive checklist
in regards to preventing medical errors. In the arena of
patient safety, experts recommend that professionals:
"¢Capture allegations of falsified medical records
related to patient care.
"¢Get regular reports on specific patient safety
initiatives at your institution.
"¢Ensure an internal reporting system exists for
major adverse events, their causes, and efforts
to prevent recurrences.
"¢Ensure patient safety issues are included on board
and executive committee agendas.
"¢Ensure clinicians and other professionals are
included in safety and quality decisions.
"¢Gather patient concerns about safety and quality.

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The Public's Perception

The Harvard School of Public Health and the Henry J.
Kaiser Family Foundation conducted a survey to gauge
both the public as well as physicians' view on medical
errors. Here is what they found:

Perceived Causes of Preventable Medical Errors
(Proportion of respondents citing as a very important cause)

Doctors not having enough time with patients:
Public 72% Physicians 37%

Overwork, stress, or fatigue of health professionals:
Public 70% Physicians 50%

Health professionals not working together or not
communicating as a team:
Public 67% Physicians 39%

Not enough nurses in hospitals:
Public 65% Physicians 53%

The influence of HMOs and other managed care
plans on treatment decisions:
Public 62% Physicians 39%

Poor training of health professionals:
Public 54% Physicians 28%

Poor supervision of health professionals:
Public 50% Physicians 16%

Poor handwriting by health professionals:
Public 48% Physicians 21%

Medical care being very complicated:
Public 48% Physicians 38%

Uncaring health professionals:
Public 47% Physicians 15%

Lack of computerized medical records:
Public 35% Physicians 13%

Source: Harvard School of Public Health
and the Henry J. Kaiser Family Foundation