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Prelude to the medical error case study
Prelude to the medical error case study
Prelude to the medical error case study
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Today, medical error has become a major and important challenge to health care systems across the globe. This is because medical errors often lead to harm that may also be non-repairable (Valiani et al. 540; Denham “Chasing Zero”). In 1999, the Institute of Medicine published a report that indicated that medical error in hospitals accounts for between 48,000 and 98,000 deaths annually (Swift et al. 78; Barger et al. 2441). As such, reducing the occurrence of medical errors has become an international concern. Poorolajal defines a medical error as “an act of omission or commission in planning or execution that contributes or could contribute to an unintended result.” (Poorolajal, et al. para 5 -10). In this case, it’s very important to acknowledge …show more content…
According to Poorolajal, medical errors occur when health care providers choose inappropriate methods of care or improperly execute an appropriate method of care (Poorolajal, et al. para 5 -10), which could potentially lead to loss of life and severe or permanent trauma to the victim. Valiani et al. argues, “Committing an error is part of the human nature” (540). Valiani et al. insist that no health care practitioner is immune to committing an error event if they demonstrate mastery of their skills (540). However, error in health care systems is dependent on many causes and factors. Management of such factors is essential to reducing the occurrence of errors in a health care system. Therefore, what strategies can medical practitioners implement to reduce medical errors? Medical practitioners can implement strategies such as communication, verification, and eliminating extended work shifts. These strategies are most effective because they help medical providers fulfill their full potential in doing their job in the most effective …show more content…
Many patients, such as children and elderly individuals are often given care, usually non-pharmacological care by caregivers in their homes. Caregivers may include parents, guardians, and even close relatives. Therefore, their involvement in the process of providing care is critical to better health outcomes and to averting medical errors (Swift et al 78). For instance, elderly individuals often suffer from cognitive deficits and functional impairments among other problems that may make them vulnerable to medical errors. Such problems may lead to misdiagnosis and eventually to medical errors. Furthermore, adolescents who are usually afforded greater responsibility for self-care is also vulnerable to medical errors. Many patients or individuals depend on their caregivers for care and also for communication. Therefore, caregivers play a critical role in the process of diagnosing, treatment, and monitoring the effectiveness of treatment for these types of patients. Caregivers may also give insight on drug use, especially Over the Counter medication and other substances that may affect the diagnosis and treatment even through drug interaction. Information provided by caregivers can help improve the process of diagnosis and avert medical errors (Neuspiel and Taylor
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).
“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.
Hospital medical errors can involve medicines (e.g., wrong drug, wrong dose, bad combination), an inaccurate or incomplete diagnosis, equipment malfunction, surgical mistakes, or laboratory errors. High medical error rates with serious consequences occurs in intensive care units, operating rooms, and emergency departments; but, serious errors that harmed patients may have prevented or minimized. Understand the nature of the error
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.
Wrong site, wrong procedure, and wrong patient errors are avoidable safety issues. Nearly 1.9 trillion dollars are spent on medical errors each year in the United States (Catalano & Fickenscher, 2008). Between 1995 and 2007, 691 wrong-site surgeries have been reported to The Joint Commission's Sentinel Event data repository (AHC Media LLC, 2008). In 2003 in response to the outcry for better patient safety The Joint Commission published their National Patient Safety Goals. Among the goals was the Universal Protocol. The Universal Protocol is actually drawn from several of the National Patient Safety Goals. It relies on multiple check points and the involvement of the entire surgical team to avoid such errors. Wrong site, wrong procedure, and wrong patient surgeries should never happen. The Universal Protocol is an evolving process which reflects the success and failures of healthcare practice, thus it requires periodic updates and policy revisions.
One consequence of a caregiver having an ageist attitude can be the overmedication of geriatric patients. Overmedication can occur if medical providers offer misguided health recommendations based
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).
In the article, “Human error theory: relevance to nurse management,” Gerry Armitage discuss the human errors in nursing and how one can make a simple medical error. This summary will identify the main idea of the article, why the researcher chooses this topic to research, and the human errors in daily nursing management and analyze them according to the human error theory. It has long been recognized that human performance at the workplace would not be perfect all the time. Human error is inescapable: “to err is human”, yet we blame the operator instead of fixing the problem. Human error can be defined as wrongdoing but not intentional by the individual, in most workplaces accidents occur because of human error.
The popular belief among our society has always been “Parents know what's best”. While they're young they know how to make their medical decisions for them. They know what's best for their children they know how to keep them safe and healthy. However their children soon turn into teenagers who should be trusted to make their own choices regarding their health care. There no longer the children they once were they can comprehend the extension of every decision they make.
Many medical professionals don’t admit to their mistakes because it is looked down upon in the medical field (Reynolds, Stone, Nixon, & Wear, 2001). There are several barriers that need to be addressed in order for medical professionals to admit to their mistakes. First, educating individuals on how to admit to their mistakes. Kelly 2007, states that many institutions don’t teach physicians on how to deal with medical errors. This should be addressed during school so that individuals who have the potential to make such medical errors know how to handle them when they arise.
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...