Chasing Zero is a documentary which was meant to both educate the viewer on the prevalence of medical harm as well as to enlighten both the public and health care providers on the preventability of these events (Discovery, 2010). The documentary expounded on the fact each year more people die each year from a preventable medical error than die due to breast cancer, motor vehicle accidents or AIDS (Institute of Medicine, 1999). Medical harm can result from adverse drug events, surgical injuries, wrong-site surgery, suicides, restraint-related injuries, falls, burns, pressure ulcers and mistaken patient identities (Institute of Medicine, 1999). Incidences of medical error have been reported in the media for many years. The most startling revelation in the documentary is how common medical errors are and how preventable they are. The Institute of Medicine (IOM) reported in 1999 that between 44,000 and 98,000 people die each year in the United States due to a preventable medical error. A report written by the National Quality Forum (NQF) found that over a decade after the IOM report the prevalence of medical errors remains very high (2010). In fact a study done by the Hearst Corporation found that the number of deaths due to medical error and post surgical infections has increased since the IOM first highlighted the problem and recommended actions to reduce the number of events (Dyess, 2009). The premise of “Chasing Zero” is to reduce the number of deaths due to healthcare harm to zero. Leading authorities on healthcare quality, such as Charles Denham, believe that all of these deaths are preventable and can be eliminated (Discovery, 2010). Dr. Denham along with the Texas Medical Institute of Technology (TMIT) are dedicat... ... middle of paper ... ...vers, clinical and non-clinical leaders of hospitals and international subject matter experts. The Texas Medical Institute of Technology, through programs such as Chasing Zero, is bringing a public voice to the issue of healthcare harm. The documentary is a stirring example of the quality issues facing the healthcare system. In 2003, the NQF first introduced the 30 Safe Practices for Better Healthcare, which it hoped all hospitals would adopt (National Quality Forum, 2010). Today the list has grown to 34, yet the number of preventable healthcare harm events continues to rise. The lack of standardization and mandates which require the reporting of events contributes to the absence of meaningful improvement. Perhaps through initiatives such as those developed by TMIT and the vivid and arresting patient stories such as Chasing Zero, change will soon be at hand.
A powerful speech given by Don Berwick on December 2004 explains ways in which healthcare industries needs to implement in order to save lives and to reduce the mortality death rates that occur in the healthcare (i.e. no needless death). In his speech entitled “Some Is Not A Number…. Soon Is Not A Time” invites all healthcare care organization U.S. and the world to come together to save 100,000 lives by June 14th 2006 at 9am exactly 18 months from the day of the speech. In order to achieve this goal Dr. Berwick suggests there should be a high standards protocol that will help improve care and reduce patients harm.
SGH has been plagued with patient quality issues, therefore SGH finds itself in a situation which is inherently antithetical to the mission of the hospital. The costs of healthcare continue to rise at an alarming rate, and hospital boards are experiencing increased scrutiny in their ability, and role, in ensuring patient quality (Millar, Freeman, & Mannion, 2015). Many internal actors are involved in patient quality, from the physicians, nurses, pharmacists and IT administrators, creating a complex internal system. When IT projects, such as the CPOE initiative fail, the project team members, and the organization as a whole, may experience negative emotions that impede the ability to learn from the experience (Shepherd, Patzelt, & Wolfe, 2011). The SGH executive management team must refocus the organization on the primary goal of patient
Hospitals are busy places, and with so much going on it is hard to believe that mistakes are not made. However, there are some accidents that should never happen. Such events have been termed ‘never events’ because they are never supposed to happen. This term was first introduced by Ken Kizer, MD, in 2001 (US, 2012). The Joint Commission has classified never events as sentinel events and asks that hospitals report them. A sentinel event is defined as, “an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof” (US, 2012). Never events are termed sentinel events because in the past 12 years 71% of the events reported were fatal (US, 2012). Because these events are never supposed to happen, many insurance companies will not reimburse the hospitals when they occur. A study in 2006, showed that the average hospital could experience a case of wrong-site surgery, one example of a never event, only once every 5 to 10 years (US, 2012). This study illustrates how rare a never event is. Hospitals do not want these never events to happen any more than a patient does. To help prevent these errors, hospitals have created policies that, if followed, will minimize the possibility of a mistake. The consequences of never events are devastating and because of this the goal is to make sure that they are eradicated from hospitals and medical facilities.
Winning the War on Healthcare Harm. Chasing Zero: Winning the War on Healthcare Harm is a documentary that discusses about the immense problem of medical errors and includes different ways and ideas on how to reduce the risk of these errors. This documentary also shows the impact medical errors have on a family’s life by showing us directly how some of the families that have been affected. Dennis and Kimberly Quaid were of the the families that went through this nightmare when their twins were accidently given Heparin (1,000 times stronger) instead of Hep-lock. Fortunately for the The Quaid’s family this avoidable medical mistake didn’t cost the twins lives.
Throughout this book, author Robert Welch demonstrates values of compassion, caution, and knowledge. These values interweave in Welch’s explanations of how the healthcare system of this country has so much money invested in it, and yet, manage patients receive so little care. This country has a healthcare system that is currently operating out of a broken model that does not place value on individual health, but on profit incentive.
Milani, Oleck and Lavie reported that Medical errors are the eighth leading cause of death in the hospitals. About 44,000 to 98,000 people die each year from adverse effects from medication errors, 1 million annually die in
Kohn, L., Corrigan, J., & Donaldson, M. (1999). To err is human: building a safer health system. Committee on Quality of Health Care in America Institute of Medicine National Academy Press Washington, D.C.
Firstly, every year there are many deaths associated with medical errors. Sarah Loughran writes, “An average of 195,000 people in the USA died due to potentially preventable, in-hospital medical errors in each of the years 2000, 2001 and 2002…” (medicalnewstoday.com) and this was just in 2000, 2001, and 2002 with the numbers bouncing higher or lower each year; nevertheless, there seems to be no end in sight for errors in the medical field. There is a way to lower these numbers drastically. The way to do this is by leveling the doctor to nurse ratio in hospitals thereby eliminating the stress factors on most nurses whom often have several patients to attend by themselves but no help in doing so. While demand for nurses may be high, there also comes a breaking point for any human being, “…factors including the high acuity of patients, inadequate nurse to patient ratios, increased work demand, and decreased resources.” (American
The purpose of this paper is to identify a quality safety issue. I will summarize the impact that this issue has on health care delivery. In addition, I will identify quality improvement strategies. Finally, I will share a plan to effectively implement this quality improvement strategy.
In saying 1.5 million Americans have witnessed hospital errors in the care of the medical center or even 40,000-100,000 deaths is a ridiculous amount of faults. Errors should be minimized, especially when dealing with people’s lives. The number of deaths is so high hospitals should take notice and really pinpoint where their facility is miscalculating and create in-service training to all employees and not just the ones that are making the errors but all employees. This will decrease the chances of errors made in the hospital. With continuous training every month there can be a huge change in the number of mistakes. The fact that these inaccuracies are even causing deaths really highlight the importance of the need for a change. Families
In the United States, hospitals and organizations find ways to help prevent events that should rarely or never occur, often called Never Events. The list of Never Events is made in order to provide hospitals with incentives to make sure the occurrences of them are reduced. As Mrs. Friend states, “If revenue decreases in our health care facilities because of “Never events” this could impact nursing in many ways. The rate of pay, staff to patient ration, availability of modern medical equipment, and our health insurance premiums will all be affected” (Friend, 2009, p. 5). One major type of Never Event that happens more often than it should is a surgical never event. Although, the occurrences of surgical Never Events may not be out of control, we must take into account that they are only reported if they are discovered. In today’s society the occurrence of Never Events should be virtually zero because of the technology available to prevent them.
It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).
Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency coordination task force with the help of government agencies. These government agencies are responsible for making health pol-icies regarding patient safety to which every HCO must follow (Schulman & Kim, 2000).
The health care is extremely important to society because without health care it would not be possible for individuals to remain healthy. The health care administers care, treats, and diagnoses millions of individual’s everyday from newborn to fatal illness patients. The health care consists of hospitals, outpatient care, doctors, employees, and nurses. Within the health care there are always changes occurring because of advance technology and without advance technology the health care would not be as successful as it is today. Technology has played a big role in the health care and will continue in the coming years with new methods and procedures of diagnosis and treatment to help safe lives of the American people. However, with plenty of advance technology the health care still manages to make an excessive amount of medical errors. Health care organizations face many issues and these issues have a negative impact on the health care system. There are different ways medical errors can occur within the health care. Medical errors are mistakes that are made by health care providers with no intention of harming patients. These errors rang from communication error, surgical error, manufacture error, diagnostic error, and wrong medication error. There are hundreds of thousands of patients that die every year due to medical error. With medical errors on the rise it has caused the United States to be the third leading cause of death. (Allen.M, 2013) Throughout the United States there are many issues the he...
There are multiple medical facilities whose workers have stated that their medical errors have reached to an alarming amount. The Institute of