Last week the World Health Organization released new guidelines for
patient safety. Why is this a big deal? Well, back
in 2000 the
Institute of Medicine released a report documenting the large-scale
problem of deaths from medical errors. The report stated that upwards
of 100,000 people in the United States were dying each year from errors
made by health care professionals.USA Today followed up on this
story in 2005, after a panel reconvened on the issue. Five years after
the original report, more people were still dying from medical errors
than accidents, breast cancer or AIDS. In that story, researchers
partially blamed the
insurance system for actually rewarding errors.
Incredibly, hospitals can profit by billing insurance companies for
more services to fix their own errors – but insurance companies often
will not pay for practices that reduce those errors.To Err is HumanNo
profession is perfect and the unfortunate truth is that mistakes are
inevitable. But the staggering number suggests there is room for
improvement. This is where the new guidelines from the World Health
Organization come in. While many of the new recommendations (especially
around hygiene safety) are already standard practice in the United
States, there are still needs for changes in this country.The
guidelines suggest preventing ‘look-alike'' and ‘sound-alike''
medications, better communication when patients are handed from one
professional to the next, and assuring
medication accuracy.The
problem extends beyond medical errors. Other reports have shown that
approximately 4,000 people die each year through the ‘proper'' use of
drugs. Folks taking prescription or over-the-counter drugs for the
right reasons still meet their demise. This could be due to allergic
reactions or other unexpected complications. Usually these deaths stem
from patients on several different medications that weren''t fully
tested for drug interactions.A Personal ExperienceMy own
family had a bit of a scare just this last week. Our 10 year old had an
allergic reaction to the anti-biotic, amoxicillin, which he was taking
for a dental infection. About a week after taking the drug, he broke
out in hives all over his body. Luckily, it was all on the outside but
sometimes this reaction can cause airway blockage and the inability to
breathe.We immediately took him off the drug, but even then the
reaction worsened and we ended up in the emergency room with a very
scared little boy. Over a 2-hour period, we saw 2 nurses, a physicians
assistant and a doctor – all independently. They all asked us the same
questions and we gave the same answers. You would think that this would
lead to the same advice.However, the PA told us that the rash
should certainly not get any worse and if it did, to bring him back in.
The doctor told us that the rash could continue to get worse for
another week and cover his whole body as a normal part of the
progression. Did they talk to each other?Also, the PA suggested
one route of more medication, which the nurse came in an started. But
when the doctor followed up she seemed unaware of the medication advice
of the PA or the fact that the nurse had just given our son a dose of
steroids.Now, I realize this was an emergency room setting and
things are a little crazy – but it was very unconvincing that he was
getting the appropriate treatment and illuminating on how medical
errors happen.The bottom line is that many people put a lot of
confidence in what their doctors tell them. After all, they went to
school for a long time to learn that stuff and you didn''t. Still, you
must be willing to ask questions and challenge their authority. If your
gut is telling you that something about their advice doesn''t quite jive
– then ask. Dig deeper until you get the sense that you should heed
their advice – you might just prevent an error yourself.