7%. They also reported the 37.4% of medication errors were caused by wrong dose or frequency, which is not far away from our result of 50.5%. (Hui, Colombia Univ. no date given) The Harvard Medical Practice Study reported that adverse events occurred in 3.7% of hospitalizations in New York in 1984, and 69% of these injuries were caused by errors" (Kuperman, et al. 1998 as cited by Hui, Colombia University no date given) There were found to be more than 250 laboratory results that contained errors although generally there were not serious consequences resulting from the errors. A few did however cause serious problems as exampled by the instance in which the "patient was started tuberculosis medication due to wrong report of positive AFB" (Hui, Colombia University nd) This error was harmful on a potential basis due to the fact that an incorrect diagnoses or mediations given to the patient could have been harmful if not fatal to that individual. The cause for wrong results or errors in lab work may be due to one of the following:
Pre-analytical: Samples from a patient in which there is a mixing up of the specimens with that of another individual.
Analytical: Map-operation of the devices; or Post-Analytical: The mixing up of patient data.
Stakeholders
Stakeholders are naturally concerned about patient safety as well as the development of strategies for identification and addressing threats to patient safety. The concern starts at the federal government and goes through the state and local governments and impacts public and private providers as well. State governments are able to "address the problem in a variety of roles, as purchasers, providers, and regulators, and others as well. Regulation of private health insurance, purchase significant amounts of health care as well as assuming responsibility for protecting the health and safety of the public.
A study published in 2000 by The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) summarizes the adverse events that are surgery linked over the past four years. There were 64 events that occurred in acute-care hospitals with 84% of the events resulting in the death of the patient and 16% resulted in the patient sustaining some type of serious injury. Ninety percent of these cases were of the nature of non-emergent type procedures. The majority of complications were found to have occurred during the 'post-operative period' with almost 25% during intra-operative procedures. The most frequent complications are inclusive of the following:
Naso-gastric feeding tube insertion into the trachea or a bronchus
Massive fluid overload from absorption of irrigation fluids
Acute respiratory failure during open orthopedic procedures
Endoscopic procedures with perforation of adjacent organs
Central venous catheter insertion into an artery
Liver laceration, peritonitis or respiratory arrest during imaging directed percutaneous biopsy or tube placement
Burns from electrocautery with a flammable prep solution
Eight 'root causes' for the problems were identified by the medical institutions. Incomplete communication was found to blame in nearly 2/3 of the cases as the 'root cause' with over 1/2 resulting from failure to adhere to procedures established in the hospitals. Other factors that were stated to be 'contributing factors' of:
1. Necessary personnel not available when needed incomplete pre-operative assessment inconsistent post-operative monitoring failure to question inappropriate orders inadequate supervision of house staff deficiencies in credentialing and privileging; and
2. Children and the elderly have been shown in the study to be much more vulnerable to medication errors than those of other age groups. An effective system to assist in the prevention of errors has been on the forefront of the minds of medical professionals since the release of the Institute of Medicine's 1999 report.
Each health care setting should have designated healthcare workers within its' institution that are in charge of the tasks of: 'Identifying and monitoring the occurrence of errors, and developing an understanding of their root causes, especially those that are preventable through,
1) Analyzing, interpreting, and disseminating data to clinicians and others in a position to effect changes within the organization;
2) Implementing error reduction strategies based on analysis and restructuring of health care systems; and
3) Seeking input as needed from experts with clinical, epidemiological, and management as well as, "
4) Training and experience for technical support and investigatory assistance; and finally evaluating the impact of these programs on patient safety.
There are several databases that are currently in use for the collection of information on specific errors. Examples of these are the Center for Disease Control and Prevention's hospital acquired infections reporting systems, The Food and
Our semester plans gives you unlimited, unrestricted access to our entire library of resources —writing tools, guides, example essays, tutorials, class notes, and more.
Get Started Now