Upload
megan
View
40
Download
1
Tags:
Embed Size (px)
DESCRIPTION
DEATH BY MEDICAL ERROR. THE HIDDEN EPIDEMIC. By William Charney. Editor of “Epidemic of Medical Errors and Hospital-Acquired Infections”. What does the term “Medical Error” mean?. A combination of medical errors where doctors, nurses or health care workers make mistakes: Medical errors - PowerPoint PPT Presentation
Citation preview
DEATH BY
MEDICAL ERROR
THE HIDDEN EPIDEMIC
By
William Charney
Editor of
“Epidemic of Medical Errors and Hospital-Acquired Infections”
What does the term “Medical Error” mean?
A combination of medical errors where doctors, nurses or health care workers make mistakes: Medical errors Health care acquired infections Misdiagnoses Medication errors Surgical errors that produce fatality or morbidity Blood clots Hospital-acquired uncontrollable diarrheas Outpatient errors Nursing home errors
Source: Dr. Gary Null and Joe Graedon, MS, and Teresea Graedon, PhD, “Top Screwups Doctors Make and How to Avoid Them”
Medical Error leading cause of death to Americans…
over 788,000 per year plus millions of injuries
Source: Extrapolation from Baker Report and the Public Health Agency of Canada
Medical Error 2nd leading cause of death to Canadians…
approximately 56,517 to 63,098 deaths per year plus 552,473 adverse events
Systemic causes of medical error have been built into the design of the systems both in Canada and U.S.
Systemic Factors in Medical Error
Profit Motive:The Journal of General Internal Medicine
published a study in March 2000, titled “Hospital Ownership and Preventable Events”. It showed that patients in for-profit hospitals are 2 to 4 times more likely than patients at not-for-profit hospitals to suffer adverse events such as post surgical complications, delays in diagnosis, and treatment of an ailment.
Source: Vol. 15 No. 3 Pgs. 211-219
Factory Medicine in Canada
Number of: Patients per dayProcedures per dayOperations per hourPatients per minuteBeds per region
Systemic Factors in Medical Error (cont’d.)
Staffing:Patients in a hospital with a 1:8 nurse-to-
patient ratio, have a 31% greater risk of dying than patients in hospitals with a 1:4 ratio.
Only state with ratio regulation is California
No Canadian province has ratio regulation
Source: Aiken, et al; JAMA 288 No. 16 (2002) 1987-92
Systemic Factors in Medical Error (cont’d.)
Shift Work:Longer shifts translate into more errors.
Physicians who are scheduled to work long hours make 36% more errors with 5 times as many serious diagnostic errors
Source: Found in "Epidemic of Medical Error" CRC Press, ed. Charney, Chapter 9 authored by Pontus pp. 191
Systemic Factors in Medical Error (cont’d.)
Behavior: A study of 1,700 nurses, physicians, clinical
care staff and administrators found fewer than 10% address behavior by colleagues that routinely includes trouble following directions, poor clinical judgment or taking dangerous shortcuts. Specifically, 84% of MDs and 62% of RNs and other clinical care providers had seen coworkers taking shortcuts that could be dangerous to patients…fewer than 10% said they directly confront their colleagues.
Systemic Factors in Medical Error (cont’d.)
Non and Under Reporting:There are 27 states in the U.S. with reporting
regulations Quebec is the only province in Canada that
has reporting regulations5% and no more than 20% of medical error
incidents are reported
Source: Leape, JAMA 1994, Dec. 21 272(23) 1851-7
Systemic Factors in Medical Error (cont’d.)
Working Conditions: Poor working conditions, such as
ergonomics, patient developmental flows, staffing, workload, scheduling, and autonomy contribute directly to medical errors. In 115 studies included in a 2003 review, working conditions affect patient safety, the rate of medication errors, and the rate of recognition of such errors after they occur
Source: Blum et al; Natural Science Sleep 3 pp. 47-85
Systemic Factors in Medical Error (cont’d.)
Accountability:Studies have shown even getting
healthcare workers to wash hands between patients or after leaving bathrooms is not enforced and there are low compliance rates
52% of doctors did not wash their hands between patients
Source: CDC, 2003
Systemic Factors in Medical Error (cont’d.)
Cost-Benefit Analysis:The Society of Actuaries has stated that
medical errors are costing $20 billion a year. Bedsores alone account for a cost of $3.9 billion annually. The cost per patient of medical error can be as high as $20,000 per bed (using the American Hospital Association’s data of 1 million hospital beds in the U.S.)
Systemic Factors in Medical Error (cont’d.)
Injury to Workers: Injury contributes systemically to medical
error and compromises patient safety. Injuring a worker leads to a downstream
negative patient effect.
Source: Charney and Schirmer, AAOHN Journal - American
Association of Occupational Health Nurses Journal)
Bullying: Nurses reported that 71% of bullying
behavior resulted in medical error of which 29% resulted in death
Systemic Factors in Medical Error (cont’d.)
Source: Rosenstein, et al. Joint Commission Quality Patient Safety 34(8) 467-71
Systemic Factors in Medical Error (cont’d.)
Technology:Reliance on technology is not a panacea for
solving medical errors. Human factors still apply.Despite computerization of pharmaceutical
approaches, 98,000 people per year end up in emergency rooms every year (mostly elderly) due to medication error.
Source: New York Times, 2012
Organizations in charge of fixing medical errors are organizations mostly responsible for creating problems
Patient advocacy groups and Canadian and American labor unions should lead the struggle to reform health care
Organizations in charge of fixing medical errors are organizations mostly responsible for creating problems
Patient advocacy groups and Canadian and American labor unions should lead the struggle to reform health care