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Health Care : Be Active
Medical Mistake Prevention

by StarStuffsOctober 2003

Since the first writing of this information, the media continues to bring up the issue of health care mistakes. ABC Nightly News, The Today Show, The News Hour with Jim Lehrer and newspapers around the country further exemplifies the need for awareness and action.

More people die from medical mistakes than people who die from AIDS/HIV. If more people become active in conventional health care practices, this too can change the health care industry and SAVE LIVES.

"estimated 15,603 AIDS-related deaths in the United States in 2001"(2)

11/03/05 "The United States leads six countries in its rate of medical mistakes" according to an international survey released 2005.

(There is much more information on this subject which may become an entire web section in the future. Information will be updated as time allows.)

Medication Errors

According to the CCH Healthcare Compliance dated 9/9/06 IOM: Medication errors common, costly

A patient hospitalized in the U.S. will experience at least one medication error each day. This translates into approximately 1.5 million preventable adverse drug events (ADEs) caused by medication errors, costing the U.S. government an estimated $3.5 billion each year. Troubled by these statistics, Congress requested in 2003 that the Institute Of Medicine (IOM) study the frequency of medication errors and formulate a national agenda to reduce its prevalence. The IOM found that medication errors are even more common than previously thought, and extremely costly to the U.S. health care system. The report suggests many areas for change, including a shift in the patient-provider relationship, increased use of information technology, improved medication labeling and packaging, as well as several policy initiatives.(4)
IOM Report: Preventing Medication Errors, July 2006

According to the National Council on Patient Information and Education (NCPIE),

"In any given week four out of every five U.S. adults will use prescription medicines, over-the-counter drugs, or dietary supplements of some sort, and nearly one-third of adults will take five or more different medications....In hospitals, errors are common during every step of the medication process from procuring the drug, prescribing it, dispensing it, administering it, and monitoring its impact -- but they occur most frequently when medicines are prescribed and administered." "When all types of errors are taken into account, a hospital patient can expect on average to be subjected to more than one medication error each day. However, substantial variations in error rates are found across facilities."

Confusion caused by similar drug names accounts for up to 25 percent of all errors reported to the Medication Error Reporting Program operated cooperatively by U.S. Pharmacopeia (USP) and the Institute for Safe Medication Practices (ISMP). In addition, labeling and packaging issues were cited as the cause of 33 percent of errors, including 30 percent of fatalities, reported to the program.

One study estimated 380,000 preventable Adverse Drug Events (ADEs) in hospitals each year, another estimated 450,000. Both estimates may be underestimates.

One study calculates that 800,000 preventable ADEs occur each year in long-term care facilities.

Another study finds that among outpatient Medicare patients there occur 530,000 preventable ADEs each year - probably also an under estimate. The IOM concludes that there are at least 1.5 million preventable ADEs that occur in the United States each year - and it may even be much higher.

The Costs of Medication Errors

One study found that each preventable ADE that took place in a hospital added about $8,750 (in 2006 dollars) to the cost of the hospital stay. Assuming 400,000 of these events each year - a conservative estimate -- the total annual cost would be $3.5 billion in this one group.

Another study looked at preventable ADEs in Medicare enrollees aged 65 and older and found an annual cost of $887 million for treating medication errors in this group." (5)

Patient's Checklist

From Dr Sanja Gupta with his interview with Oprah Winfrey October 3, 2003.

Neurosurgeon Sanjay Gupta reports on medicine and health for CNN. He says that an informed patient is a safer, smarter patient.

Know Your Condition

Get a thorough description of your condition or diagnosis from your doctor in writing. One of Oprah's friends recently took a tape recorder to her doctor's office, so that she could go over everything later. (It was also mentioned to utilize the internet to investigate your diagnosis.)

Beware of Unusual Medical Degrees

Don't be shy about asking your physician about his or her accreditations. And don't trust anyone who claims to have an exclusive treatment.

Track Record

Investigate your doctor's track record, success rate, and whether he's ever been sued for malpractice. (It was mentioned that there are web sites that document malpractice.)

Get a Second Opinion

Your doctor shouldn't take personal offense if you decide to get another professional's opinion. (If you are undergoing a serious ordeal, always get a second opinion in another facility- it's your health!!)

What's New?

Find out if your surgeon is up to date on new techniques. Some older surgeons are not. (Again, do some checking online yourself, don't be afraid to ask and talk with the doctors and surgeons.)

Ask, Ask, Ask

Ask who will be doing the operation, and how long your doctor will have been awake before your operation is scheduled. Dr. Gupta recommends asking if your surgery can be performed early in the morning and early in the week. That's when doctors are more likely to be fresh. (He mentioned that statistically, people who have been up for 24 hours and/or pulled a double shift is equivalent to being legally drunk in mind and motor skills.)

Mark Your Body

Use a marker on your body to designate where you shouldn't be cut. This can help prevent accidental mistakes like operating on the incorrect knee. (Dr. Gupta said there are post-its you can buy that say "Do Not Cut Here" (can you believe it?). You shouldn't be afraid to mark on yourself and/or have the doctor/surgeon do it.)(3)

An article to reitterate this situation:

Hospital complications take huge toll

More than 32,000 deaths and $9 billion in costs a year: report

CHICAGO, Oct. 7, 2003 - Postoperative infections, surgical wounds accidentally opening and other often-preventable complications lead to more than 32,000 U.S. hospital deaths and more than $9 billion in extra costs annually, a report suggests.

"..complications contribute to 2.4 million extra days in the hospital each year...medical mistakes kill anywhere from 44,000 to 98,000 hospitalized Americans a year...Many of the 18 complications, including medical objects left inside patients after surgery, are preventable medical errors. " (1)

The Boston Globe
Medication errors injure more than 1.5 million
Many mistakes preventable, study concludes
July 21, 2006

More than 1.5 million Americans are injured every year by drug errors in hospitals, nursing homes and doctorís offices, a count that doesnít even estimate patientsí own medication mix-ups, says a report that calls for major steps to increase patient safety.

Topping that list: All prescriptions should be written electronically by 2010, the Institute of Medicine said. At least a quarter of all medication-related injuries are preventable, the institute concluded in the report it released Thursday.

"..hospitals commit 400,000 preventable drug errors each year, that is $3.5 billion.." (6)(7)

The report's recommendations include electronic presciptions, aggressive questioning to health care providers along with "The nation should invest about $100 million annually on research into drug errors." This is clearly a problem the U.S. cannot ignore.

Washington Post
Medication Errors Harming Millions, Report Says
Extensive National Study Finds Widespread, Costly Mistakes in Giving and Taking Medicine
July 21, 2006

Following up on its influential 2000 report on medical errors of all kinds, the institute, a branch of the National Academies, undertook the most extensive study ever of medication errors in response to a request made by Congress in 2003 when it passed the Medicare Modernization Act. The report found errors to be not only harmful and widespread, but very costly as well. (11)

100,000 Lives Campaign

Dr. Donald Berwick, President and CEO of the Institute for Health Care Improvement and a Harvard professor, orchestrated a campaign to save lives by getting U.S. hospitals to improve their care in order avoid medical mistakes and prevent infections. 3,100 hospitals participated in the project bringing together health care groups, hospitals, doctors and nurses. This number is about two-thirds of the community hospitals nationwide. The target goal of 100,000 lives nationwide over a year and a half. The target date of 2004 has already vastly exceeded. By sharing mortality data and implementing studied and tested procedures an estimated 122,342 lives have been saved according to the interview transcript on August 18, 2006 with Jim Lehrer. (9)

"I think this campaign signals no less than a new standard of health care in America," said Donald Berwick (8)

"We in health care have never seen or experienced anything like this," said Dr. Dennis O'Leary, president of the Joint Commission on Accreditation of Healthcare Organizations (8)

"Never Events"

"..serious and costly errors in the provision of health care services that should never happen. "Never events," like surgery on the wrong body part or mismatched blood transfusion, cause serious injury or death to beneficiaries, and result in increased costs to the Medicare program to treat the consequences of the error."

"..are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility.."

2003 - the Minnesota legislature, was the first to pass a statute requiring mandatory reporting of "never events". In two years there were 205 incidents reported, 32 were deaths and 13 were serious disabilities/injuries.

2004 - New Jersey enacted a law requiring hospitals to report "never events".

2005 - Illinois law passed will require hospitals and ambulatory surgery centers to report 24 "never events" beginning in 2008.

..our health care system still has not reached the IOMís goal of a 50 percent reduction in the number of deaths due to medical errors. Consequently, working with provider associations and other public and private groups, the Centers for Medicare & Medicaid Services is taking further steps to prevent "never events." Several other states have considered or are currently considering never event reporting laws. (10)

Tips to help prevent medical errors:

** The single most important way you can help to prevent errors is to be an active member of your health care team. That means taking part in every decision about your health care. Research shows that patients who are more involved with their care tend to get better results. Some specific tips, based on the latest scientific evidence about what works best, follow.

** Make sure that all of your doctors know about every medicine you are taking. This includes prescription and over-the-counter medicines, and dietary supplements such as vitamins and herbs. It is a good idea to maintain a list of medicines, vitamins and other products that you are taking. At least once a year, bring all of your medicines and supplements with you to your doctor. "Brown bagging" your medicines can help you and your doctor talk about them and find out if there are any problems. It can also help your doctor keep your records up to date, which can help you get better quality care.

** Make sure your doctor knows about any allergies and adverse reactions you have had to medicines. This can help you avoid getting a medicine that can harm you.

** When your doctor writes you a prescription, make sure you can read it. If you can't read your doctor's handwriting, your pharmacist might not be able to either. Check to make sure the name of the brand/generic medication and the directions the same as prescribed.

** Ask for information about your medicines in terms you can understand-both when your medicines are prescribed and when you receive them. Know that you the right to pharmacist counseling.

  • What is the medicine for?
  • How am I supposed to take it, and for how long?
  • What side effects are likely?
  • What do I do if they occur?
  • Is this medicine safe to take with other medicines or dietary supplements I am taking?
  • What food, drink, or activities should I avoid while taking this medicine?
  • Is there written information about the medication you can have?

** When you pick up your medicine from the pharmacy, ask: Is this the medicine that my doctor prescribed? A study by the Massachusetts College of Pharmacy and Allied Health Sciences found that 88 percent of medicine errors involved the wrong drug or the wrong dose.

** If you have any questions about the directions on your medicine labels, ask. Medicine labels can be hard to understand. For example, ask if "four doses daily" means taking a dose every 6 hours around the clock or just during regular waking hours.

** Ask your pharmacist for the best device to measure your liquid medicine. Also, ask questions if you're not sure how to use it. Research shows that many people do not understand the right way to measure liquid medicines. For example, many use household teaspoons, which often do not hold a true teaspoon of liquid. Special devices, like marked syringes, help people to measure the right dose. Being told how to use the devices helps even more.

** Ask for written information about the side effects your medicine could cause. If you know what might happen, you will be better prepared if it does-or, if something unexpected happens instead. That way, you can report the problem right away and get help before it gets worse. A study found that written information about medicines can help patients recognize problem side effects and then give that information to their doctor or pharmacist.

** If you have a choice, choose a hospital at which many patients have the procedure or surgery you need. Research shows that patients tend to have better results when they are treated in hospitals that have a great deal of experience with their condition.

** If you are in a hospital, consider asking all health care workers who have direct contact with you whether they have washed their hands. Handwashing is an important way to prevent the spread of infections in hospitals. Yet, it is not done regularly or thoroughly enough. A recent study found that when patients checked whether health care workers washed their hands, the workers washed their hands more often and used more soap.

** When you are being discharged from the hospital, ask your doctor to explain the treatment plan you will use at home. This includes learning about your medicines and finding out when you can get back to your regular activities. Research shows that at discharge time, doctors think their patients understand more than they really do about what they should or should not do when they return home.

** If you are having surgery, make sure that you, your doctor, and your surgeon all agree and are clear on exactly what will be done. Doing surgery at the wrong site (for example, operating on the left knee instead of the right) is rare. But even once is too often. The good news is that wrong-site surgery is 100 percent preventable. The American Academy of Orthopaedic Surgeons urges its members to sign their initials directly on the site to be operated on before the surgery.

** Speak up if you have questions or concerns. You have a right to question anyone who is involved with your care.

** Make sure that someone, such as your personal doctor, is in charge of your care. This is especially important if you have many health problems or are in a hospital.

** Make sure that all health professionals involved in your care have important health information about you. Do not assume that everyone knows everything they need to.

** Ask a family member or friend to be there with you and to be your advocate (someone who can help get things done and speak up for you if you can't). Even if you think you don't need help now, you might need it later.

** Know that "more" is not always better. It is a good idea to find out why a test or treatment is needed and how it can help you. You could be better off without it.

** If you have a test, don't assume that no news is good news. Ask about the results. (1)

The subject of people dying from their hospital stays ran on Dateline in October 2003. The culprit and focus of this investigation is the notable "staph infection".

One medical official said there was not a problem with this. However, the statistics seem to say there is. 1/2 of all hospital deaths, over 10 thousand deaths are preventable, simply by health care workers washing hands AND there medical supplies such as stethoscopes, before/after patient contact.

Simply washing!! can save lives.

Again, be active in your health care!!!

Demand nurses and doctors wash before touching you or a loved one.

Remember, your health is important and you do have a say how you are treated within a health care situation.

Blessings of Health and Happiness
StarStuffs

For more information:

United States Department of Health and Human Services
Health Care: Medical Errors Resource page

Medical Errors and Patient Safety
Speeches, Statements and Hearings
http://www.ahrq.gov/qual/errorsix.htm

Report to the President on Medical Errors

References:

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)

writing ammended August 2005