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Health care safety issues

Mistakes happen: how they can be minimized

The healthcare system of the United States is a loosely structured system composed of many parts (hospital, outpatient, rehabilitation centers, nursing home, insurance payers, etc.) that do not directly communicate within one centralized, nationwide information system. Because of the system’s complexity, errors can be made that adversely affect the individual seeking care. For example, a 2006 IOM (Institute of Medicine) study found that medication errors are among the most common medical mistakes, harming at least 1.5 million people every year.

This article describes the different types of potential problems that can occur and ways that institutions and health care professionals are attempting to decrease errors, hospitalizations and improve outcomes for all of us.

Classes of error

The medical profession has a number of phrases used to define different types of error. An “adverse event” is when any harm occurs from the treatment and not from the disease. An “error” as defined by the National Quality Forum is “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.” Other terms used in the medical literature include “near miss” (an event that did not produce harm, but only because of intervening factors or a last-minute intervention) and “preventable event” (an event that could have been anticipated and prepared for, but occurs because of an error or system failure).

Common types of medical errors

Diagnostic error is the most common reason for malpractice claims against physicians or institutions. It relates to either failure to diagnose or delayed diagnosis. It is estimated that 5% of adults seeking ambulatory care will experience a diagnostic error that has the potential to be harmful or fatal.

Drug error can occur at any point in the process it takes to obtain a prescription medication and taking it correctly. Incorrect prescribing by the health care practitioner, dispensing errors by the pharmacy, incorrect understanding of how to take the medication and delayed monitoring of the effect of the drug can all lead to preventable hospitalizations, permanent harm and potential death. Many older adults are taking five or more drugs that can lead to potentially harmful drug interactions and adverse side-effects.

Testing errors occur due to the breakdown of ordering, processing the test in the lab or facility, mix-up in correct patient reporting, failure to report a result (lost test result) and follow-up with the patient of an abnormal result. The exact incidence of this problem is unclear, but because of the large volume of test results received in a busy practice, it does occur. This can lead to a patient not be notifying of an abnormal result and delays in obtaining further diagnostic testing and treatment.

Care transition communication issues are the leading cause for adverse events and higher medical costs from readmissions to the hospital. Examples of transitions are when a person is discharged from hospital back to his/her primary care physician, transfer to a rehabilitation center or nursing home and communication between physicians. There is the potential for incomplete or incorrect information in the discharge documents. 

Solutions

Electronic medical records (EMR) systems. Hospitals and physician offices are now routinely using EMR software to document all interactions, order tests, prescribe medication and remind the health care provider about needed testing or screening. These systems have decreased errors due to poor handwriting and misinterpretation of names of drugs and dosages. These systems are not perfect and depend on the accuracy of data entered into the system.

Because many test results are transmitted back to physician offices by digital methods, systems exist that require a designated person in the practice to review the result and then transfer it to the person’s file. Many doctors in our area have created patient-ports that allow the individual to view the written results online as well as communicate questions back to the physician without the need of a telephone call.

Hospital-based interventions. Hospitals are responsible for following up with individuals after discharges. Lack of follow-up with a community health care provider is a major reason why people are readmitted within 30 days. Because of EMR systems, written reports are generated at the time of discharge that are shared with the patient and family, along with discharge summaries, laboratory testing and consultant reports being sent or transmitted back to the treating doctor. 

Some hospitals are setting up a hospital-based, post-discharge bridge clinic that will see the person until a follow-up appointment can be made with the person’s physician.

A new technology being used in some practices and hospitals follows up with patients using video technology in which the physician and patient “meet” online to monitor how the person is doing. This works well for individuals with chronic disease who have problems getting to the doctor’s office.

Patient responsibility. An equal part of preventing errors from occurring is for the individual and his/her family to have a clear understanding of the diagnosis and treatment prescribed. Asking for clarification of treatment procedures and follow up is essential. If English is not the person’s primary language, hospitals and doctors’ offices can provide translation services.

 

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