Disturbing news - No decline in medical errors

Wes Bucey

Quite Involved in Discussions
#1
I'm a long time member of the Institute for Healthcare Improvement. My news feed brought me some upsetting news this evening
Despite Efforts, Study Finds No Decline in Medical Errors

But experts say some safety initiatives may take time to bring results

By Maureen Salamon
WEDNESDAY, Nov. 24 (HealthDay News) -- Despite intensive efforts to improve patient safety, a six-year study at 10 North Carolina hospitals showed no decline in so-called patient "harms," which included medical errors and unavoidable mistakes.

Sorting through patients' medical records from more than 2,300 randomly selected hospital admissions, teams of reviewers found 588 instances of patient harm, which included events such as hospital-acquired infections, surgical errors and medication dosage mistakes.

While most harms were minor and temporary, 50 were life-threatening, 17 resulted in permanent problems and 14 people died, said the researchers, who selected North Carolina hospitals because the state has shown a strong commitment to patient safety. The admissions records spanned the period from January 2002 to December 2007.

Study author Dr. Christopher Landrigan said the results likely reflect what's happening nationwide. A 1999 Institute of Medicine report publicizing high medical error rates spurred many U.S. hospitals to implement safety-promoting changes, but no uniform set of guidelines exists to direct facilities which changes to tackle, he said.
Any suggestions on what we, as Quality professionals can offer to improve the statistics?

When I was much younger, I sat in on a mortality and morbidity session at a hospital my firm was financing. I offered one suggestion on a minor change and was treated with scorn. The exact words, burned into my memory, were, "You are here to observe as a courtesy to the hospital Chairman. That does not give you the right to speak. Only healthcare professionals may actually participate or even ask questions."

I suspect some of those old attitudes may still be prevalent among healthcare professionals still suffering from a "god complex." What has been YOUR experience?

After all, these folks claim they were "trying" to improve, but SIX YEARS of no results implies their efforts were misdirected.
 
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SteveK

Trusted Information Resource
#2
Hi Wes,

I don’t know about improving statistics, but if you think things are bad in the US just look at this recent UK story:

http://www.bbc.co.uk/news/health-11696735

My experience of ‘healthcare’ (is that an oxymoron?) is don’t get ill enough to be admitted to hospital – it is a dangerous place to be – this is from personal (near death) incidents. But getting back to statistics, I guess from sales enquiries etc for our medical devices, I could gather some useful quality data. This would focus on the number of ‘healthcare’ professionals who do not know how to use (or know what they are for) some fairly simple medical devices.:mg:

Steve
 

rob73

looking for answers
#3
The biggest bugbear I have with the medical profession is the ability and attitudes of some to close ranks to protect on another when something goes wrong. There have been instances where devices that have "failed" are destroyed before we can investigate, then the medicals staff will swear blind that something went wrong with the device even though you can show that it would be physically impossible to do so.:mad:
Until the medical profession can hold its hands up and show complete transparency when something goes wrong, things will never improve.

I can say though that I do have the greatest respect for these people. I know they work under extremes of pressure and they often quite literally hold people lives in the hands and for the majority do a great job so a big :applause:for them.
Rob
 

Wes Bucey

Quite Involved in Discussions
#4
Hi Wes,

I don’t know about improving statistics, but if you think things are bad in the US just look at this recent UK story:

http://www.bbc.co.uk/news/health-11696735

My experience of ‘healthcare’ (is that an oxymoron?) is don’t get ill enough to be admitted to hospital – it is a dangerous place to be – this is from personal (near death) incidents. But getting back to statistics, I guess from sales enquiries etc for our medical devices, I could gather some useful quality data. This would focus on the number of ‘healthcare’ professionals who do not know how to use (or know what they are for) some fairly simple medical devices.:mg:

Steve
the problem is world-wide - the situation revolves around whether the healthcare people have enough clout to bury (pun intended) their mistakes without retribution.
 

Wes Bucey

Quite Involved in Discussions
#5
The biggest bugbear I have with the medical profession is the ability and attitudes of some to close ranks to protect on another when something goes wrong. There have been instances where devices that have "failed" are destroyed before we can investigate, then the medicals staff will swear blind that something went wrong with the device even though you can show that it would be physically impossible to do so.:mad:
Until the medical profession can hold its hands up and show complete transparency when something goes wrong, things will never improve.

I can say though that I do have the greatest respect for these people. I know they work under extremes of pressure and they often quite literally hold people lives in the hands and for the majority do a great job so a big :applause:for them.
Rob
I agree with the transparency issue, but my initial post shows transparency, but also ineffective "corrective action." WHY are their actions ineffective?
What can we Quality professionals do to steer them right?
 

rob73

looking for answers
#6
[FONT=&quot]This is local to me,
http://www.bbc.co.uk/go/em/fr/-/news/uk-england-devon-11824592
Frankly I do not care how many apologies the management give and how many assurances that "things are better now", its too late for the "victim" and their relatives. I find it a very sad state of affairs, I have no confidence that NHS management or the health department will change things (in a positive way) any time soon.
Rob.


[/FONT]
 

rob73

looking for answers
#7
I agree with the transparency issue, but my initial post shows transparency, but also ineffective "corrective action." WHY are their actions ineffective?
What can we Quality professionals do to steer them right?
Not sure about the US, but the NHS is overladen with middle management who's sole purpose is to collect and report on operating efficencies and targets, apparently there are more administrators than doctors in some hospitals.
Maybe retraining some of these "administrators" to be safety officers or auditors following a proper QMS based reporting system and ensuring a good continual improvement and CAPA process would be a good start.
Rob
 

Jen Kirley

Quality and Auditing Expert
Staff member
Admin
#8
I don't know details about what this group of health centers did, but in a different study - Boston, I think - I recall reading that using checklists in the operating rooms reduced problems like "re-entry" (to retrieve a sponge or something) by 30 percent.
 

Jim Wynne

Staff member
Admin
#9

SteveK

Trusted Information Resource
#10
Training with respect to quality (and thus quality of care) is an issue – as I have already alluded to. Only few hours ago a Medical Devices Trainer contacted us about an oxygen flowmeter (for oxygen therapy) as used on hospital wards. Apparently our Operating Instructions (OIs) were too complicated (they are not!). Quote “although this (OIs) is useful it’s not really suitable for our ward areas etc as they need a more basic, how to change a flowmeter, how to read it etc”. Note: nurses nowadays have degrees!

Steve
 
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