Throughout history, there has been a countless number of issues regarding the quality and safety of healthcare. As many of these issues are being addressed and solved, there is still a growing number of medical errors that are being studied to find a solution. One of these complications is “wrong site surgery (WSS)” (Adams, Fraser, 2006) . A wrong site surgery occurs when an invasive or surgical procedure is performed on the wrong site, the wrong patient, or if the wrong procedure has taken place; these instances are known as “WSPEs” (AHRQ, 2017). These are serious events that can have irreversible consequences for both patients and healthcare providers, and all three can take equally serious tolls upon patients. These shocking and avoidable …show more content…
(AHRQ, 2017).
Despite wrong site surgeries having the aforementioned title of “never events”, such mistakes still occur all too commonly. In fact, one study’s findings reveal that wrong site surgeries happen roughly one in 112,000 procedures, meaning that on average, a single hospital would see such an incident between every five and ten years (Cohen, 2016). Such mistakes, additionally, are not limited to inexperienced medical professionals. Although some defended renowned surgeon Dr. Rolando R. Sanchez on the basis of his overwhelmingly successful track record, his failure to check the paperwork and follow standard procedure led to him amputating the wrong leg of a patient, and to the loss of his medical license (NY Times, 1995). Similarly, in 2016, a Massachusetts surgeon was under investigation for allegedly removing a kidney from the wrong patient after an undisclosed
…show more content…
One project aimed at this was called Robust Process Improvement (RPI). Researchers used RPI to pinpoint causes, measure the magnitude of a problem, and establish solutions (Joint commission, 2014). After using RPI at eight different hospitals, four root causes were found. The first one being scheduling. Some scheduling problems that led to WSS include: schedulers not accurately documenting, unapproved abbreviations, illegible handwriting and cross-outs. The second cause was within pre-op/holding. Examples of these errors are: primary documents being incorrect or missing, inconsistent use of site-marking, inconsistency or lack of the time-out process, and defective patient verification. The third cause is within the operating room. Some examples of defects within this area include: no site verification by the provider who performs the same procedure multiple times, ineffective hand-off communication, site marks being removed during prep, and a time-out happening before all staff members are present. The fourth cause is organizational culture. Examples of this include: poor organization surrounding patient safety, the staff does not speak out about wrongdoings, and staff does not follow policy changes (Joint Commission, 2014). With the root cause of these problems identified, more solutions should be established to rectify the
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).
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.
Surgical errors are seen in every hospital; however, hospitals are not required to report such incidents. Unintended retained foreign objects, often abbreviated as URFOs, are among those events that are often not reported.
Medical error occurs more than most people realize and when a doctor is found negligent the patient has the right to sue for compensation of their losses. Debates and issues arise when malpractice lawsuits are claimed. If a patient is filing for a medical malpractice case, the l...
The world of healthcare changes every day. Technology, as we know it evolves and changes the actual care that patients receive and even post care as well. It has been determined that most faults are caused by system failures. When a break in the system has occurred it must then be decided where the,” inefficiencies, ineffective care and preventable errors” to then influence changes within the broken system (Hughes, 2008). Improvements sometimes can begin with measurements and benchmarks which in turn will allow organizations to assess the trouble spots and broken areas within the system. Many times those broken areas within the system will be owned by the humans who operate within these systems. According to the Institute of Medicine (IOM)
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
He said, “Studies of specific types of error, too, have found that repeat offenders are not the problem. The fact is that virtually everyone who cares for hospital patients will make serious mistakes, and even commit acts of negligence, every year. For this reason, doctors are seldom outraged when the press reports yet another medical horror story. They usually have a different reaction: This could be me. The important question isn’t how to keep bad physicians from harming patients; it’s how to keep good physicians from harming patients” (658). Like Gawande asked—how do you keep good physicians from harming patients? Even the best of doctors and surgeons manage to make mistakes that led to being sued or even worst—they get to experience the death of their
Today’s healthcare environment is facing tremendous challenges in order to ensure safe, quality care, while simultaneously providing affordable care that is still able to produce revenue. With continuously escalating healthcare demands emerging from the population, healthcare providers and professionals have no choice but to accept these challenges and put forth the best possible approach to meet these demands involving patient care. New ideas for managing tests, medications, procedures, orders and delivery of care must continuously be considered by the healthcare organizations to ensure that the care they provide is appropriate, safe, efficient and cost effective. Periodically providers run into trouble by ordering unnecessary or duplicated tests and/or medication errors, which cause delays in care and have the potential of diminishing patient outcome. In these cases, an ongoing workflow process is essential to ensure that patients receive the best possible care and generate greater outcomes for both patient and the provider.
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
The purpose of this paper is to distinguish, outline, and evaluate the affects that workarounds have on patient safety and quality. According to Alexander, Frith, and Hoy (2015), a workaround is defined as when a problems arise within the workflow and a worker uses an unauthorized way around the health information technology system. This being said, workarounds are present in the hustle and bustle of the stressful hospital workflow, and in return can potentially lead to negative consequences. Therefore, it is essential for health care professionals to recognize the workaround, analyze their workflow, and then develop possible solutions.
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.
Many hospitals have systems of checks and balances to avoid errors, but what happens when the systems do not work? Today in the United States, medical errors are the fifth-leading cause of death. In 2000, the Institute of Medicine released a study, “To Err is Human”, revealing an estimated 98,000 deaths annually from medical errors. While this figure is assumed to be lower than the actual, each death comes with an inherent cost to the health care system. In today’s terms this figure is underestimated, however the accompanied cost is estimated to be between $17 billion and $29 billion annually.
One of the most common examples of medical malpractice is wrong-site surgery (WSS). Wrong-site surgery is not only a liability risk, but it is a clinical, financial, and business risk as well. It is also considered a “never event” on the Center for Medicare and Medicaid Services’ list of never events. “The CMS adheres to the NQF definition that never events are (1) errors in medical care that are clearly identifiable and preventable, (2) serious in their consequences for patients, and (3) indicate a real problem in the safety and credibility of a healthcare facility” (Youngberg, 2011). Not only is wrong-site surgery an issue but so is wrong-patient and wrong-procedure.
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).
We act like animals, we eat like animals, and we are animals. The many theories of evolution such as Darwin's theory of evolution prove to us that we choose to believe that we are not animals when we really are. Evolution is the sequencial process of change over periods of time, which shapes and establishes the formation of modern man. In referring to evolution, the word means various changes. Evolution refers to the fabrication and development of life on earth. "Organic evolution" is the concept that all living beings evolved from simple organisms and have changed throughout the periods of time to create many and various types of species.