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Errors in the health care system
Errors in the health care system
Healthcare ethics case study chapter 2
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It’s very difficult to blame someone when mistakes occur in an environment in which we hope learning and improvement will take place. But eventually someone has to take blame for the mistake. Errors can occur anywhere but when it comes to the healthcare field there are more possibilities.It would include acute care, ambulatory care, outpatient clinics, pharmacies, and patient homes. Many people assume that medical errors involve only wrong medications administered or the wrong surgery performed (Dovey, Kuzel, Phillips, and Woolf, 2004). However, there are many other types of errors such as wrong diagnosis, equipment failure; sometimes patients are given the wrong blood (Dovey, Kuzel, Phillips, and Woolf, 2004). As much as the healthcare employees try to prevent medical errors, they still can happen. It is necessary to recognize the medical error in order to provide proper care to the patient, report the error and then take an action to prevent the error from happening again (Dovey, Kuzel, Phillips, and Woolf, 2004).
The sentinel events are the worst. They involve death, psychological injury, or the "risk thereof." "Risk thereof" means that although death or serious injury may not have happened it could have happened (Dovey, Kuzel, Phillips, and Woolf, 2004). An idea came up of not paying the hospitals or facilities if the patients are being charge for their mistakes. “The idea of not paying for errors was spawned by the quality improvement movement that has been sweeping through healthcare since 1999, when the institutes of medicine issued its seminal report saying as many as 98,000 U.S died annually because of medical errors” (Carpenter, 2008) (p.14). Perhaps maybe this can fix the medical error problem we are having.
Preven...
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...selves and often suffer long-term guilt.
Works Cited
Carpenter, D. (2008). Never Land Medicare Declares “No Pay for Preventable Errors”. http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=8&sid=f99326c5-50b6-4b3c-a20a-31ffaf7233b9%40sessionmgr4001&hid=4214.
Dovey, S., Kuzel, A., Phillips, R. Woolf, S. (2004). A String of Mistakes: The importance of Cascades Analysis in Describing, Counting, and Preventing Medical Errors. Annals of Family Medicine, v.2 (4). doi: 10.1370/afm.126.
Ferrer, J., Koepke, C., Miranda, D., Swift, E. (2001). Preventing Medical Errors. Health Care Financing Review, v.23(1) http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=f99326c5-50b6-4b3c-a20a-31ffaf7233b9%40sessionmgr4001&vid=5&hid=4214.
Moridani, M., Scott, T. (2012). Lookalike, Soundalike Tests: Preventing Serious Medical Errors. Letters to the Editor, v.28. doi:10.5858/arpa.
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).
Kohn, L. et al. 2000. To err is human: building a safer health system. Washington D.C. National Academies Press.
“When Doctors Make Mistakes” narrates an event where the author Atul Gawande, a doctor, made a mistake that cost a women her life. He relates that it is hard to talk about the mistakes that occurred with the patient's family lest it be brought up in court. In that instance the family and doctor are either wrong or right, there is no middle ground in a “black-and-white mortality case”(658). Even the most educated doctors make simple mistakes that hold immense consequences but can only speak about them with fellow doctors during a Morbidity and Mortality Conference.
In the essay “When Doctors Make Mistakes” written by Atul Gawande, he writes a first-hand account of mistakes made by himself and his colleagues. The essay is divided into five parts, each named to the narrative and emotions of the story he would tell. In each story he tells, he uses such vivid language that we as readers feel as if we are one of his colleagues. Each section has its own importance to the whole point he was trying to get across, ““All doctors make terrible mistakes” (657).
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.
I have been aware of medical errors for some time now. While in nursing school I have heard many stories from classmates and instructors of instances where people they knew, or loved ones had been either harmed or died because of a medical error. I have had experiences with medical errors. When I was in the hospital for the birth of my first child, the nurse that came to change out my IV bag did not check the
There are many ways to classify the sentinel event, one of the most useful regarding the definition of ethics, criminal, civil and administrative liability, it is one that divides it into preventable and non-preventable sentinel event. The sentinel event is not preventable complication that can not be prevented given the current state of knowledge; the sentinel event is preventable bad outcome of care that can be prevented with the state of knowledge.
There are a few types of medical errors discussed in Patient Safety Principles & Practice. One of them is an error of execution. An error of execution is when a correct action does not proceed as intended. It is a failure of a planned action to be completed as first intended. It occurs unintentionally during an automatic performance of patient care. This error is almost always observable at the patient and caregiver interface.
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.
Medication errors made by medical staff bring about consequences of epidemic proportions. Medical staff includes everyone from providers (medical doctors, nurse practitioners and physician assistants) to pharmacists to nurses (registered and practical). Medication errors account for almost 98,000 deaths in the United States yearly (Tzeng, Yin, & Schneider, 2013). This number only reflects the United States, a small percentage in actuality when looking at the whole world. Medical personnel must take responsibility for their actions and with this responsibility comes accountability in their duties of medication administration. Nurses play a major role in medication error prevention and education and this role distinguishes them as reporters of errors.
To most of society, medical errors reflect poorly on a doctor. Many accuse the physician of being negligent and incompetent in the event of a medical error, but the truth is they are simply human. The stigmatization of medical errors is a result of the high, almost god-like, expectations society has placed upon physicians. In his book Complications: A Surgeon’s Notes on an Imperfect Science, Dr. Atul Gawande highlights several reasons doctors have trouble admitting their medical mistakes and why they shouldn’t.
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).
As humans when we are faced with any psychological or emotional problems, our initial thought is to turn to a therapist, doctor or any other health practitioners. Our initial thought when we are faced with problems regarding our health is to turn to a health professional because for ages that’s how it has been. When it comes to our health, health professionals nowadays do more harm than help. Many might disagree, but often patients are misdiagnosed with mental illnesses they do not have. Misdiagnosis occurs when a therapist or other health practitioners decide that a patient is suffering from a condition that he or she may not be suffering with. When misdiagnosed, patients are given unnecessary treatment, which could potentially
Mahar.M, (2011). Reducing the Cost of Medical Errors: Spend a Little to Save a Little. Retrieved on March 29, 2014 from http://www.healthbeatblog.com/2011/04/patient-safety-when-targeted-spending-trumps-indiscriminate-cuts-to-medicare