Medical Errors Awaiting Prevention

Attached a link http://www.nytimes.com/2012/01/06/health/study-of-medicare-patients-finds-most-hospital-errors-unreported.html to an interesting article titled "Report Finds Most Errors at Hospitals Go Unreported" pointing out that according to recent federal study hospital employees recognize and report only one out of seven errors, accidents and other events that harm Medicare patients while they are hospitalized. According to the study, from Daniel R. Levinson, inspector general of the Department of Health and Human Services, some of the most serious problems, including some that caused patients to die, were not reported.The inspector general estimated that more than 130,000 Medicare beneficiaries experienced one or more adverse events in hospitals in a single month. Many hospital administrators acknowledged that their employees were underreporting injuries and infections that occurred in the hospital, he said. More often, Mr. Levinson said, the problem is that hospital employees do not recognize “what constitutes patient harm” or do not realize that particular events harmed patients and should be reported. In some cases, he said, employees assumed someone else would report the episode, or they thought it was so common that it did not need to be reported, or “suspected that the events were isolated incidents unlikely to recur.”The inspector general found that “hospitals made few changes to policies or practices” after employees reported harm to patients. In many cases, hospital executives told federal investigators that the events did not reveal any “systemic quality problems.”Organizations that inspect and accredit hospitals generally “do not scrutinize” how hospitals keep track of medical errors and other adverse events, the study said. The federal investigators did an in-depth review of 293 cases in which patients had been harmed. Forty of those cases were reported to hospital managers, and 28 were investigated by the hospitals, but only five led to changes in policies or practices, the study said. What are possible solutions? 1) Train staff to report medical errors and to automatically flag those patients within an electronic health record for IMMEDIATE quality assurance review 2) Utilize software which automatically triggers alerts for diagnoses and conditions including medication errors, severe bedsores, infections that patients acquire in hospitals, delirium resulting from overuse of painkillers and excessive bleeding linked to improper use of blood thinners. 3) Deploy medical error prevention teams within hospitals to educate staff and to assist in the implementation of lessons learned from a root-cause analysis into the clinical practice. I am confident that we can achieve our goals to reduce medical errors and to save lives. Yours Bernd