The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man. GB Shaw
Showing posts with label Death Medication Safety. Show all posts
Showing posts with label Death Medication Safety. Show all posts
Monday, March 14, 2011
Reporting Poor Performance by Doctors
A very concerning piece, but not that surprising to those in practice. A study of >1000 UK doctors found that almost 30% would not report concerns about a colleagues poor performance. The main reason for this was concerns about retribution. It brings to mind a conference I attended 2 years ago in which a keynote speech was by three well known, (non-nmedical) whistleblowers. They made the point that whistleblowers are often motivated by anger or revenge, and that if they were faced with the situation again, they would not reveal their misgivings. This was very sobering; one assumes that whistleblowers (an awful term) are motivated by altruism.
Monday, December 6, 2010
IHI Forum
I am attending the annual IHI forum, in Orlando far away from the arctic conditions at home. Amazing stuff, spending the day at a course devoted to paediatric patient safety, with talks from the worlds experts in this area. Steve Muething, Cincinnati Children's talks about developing a high reliability organization in healthcare. Matt Scanlon, Milwaukee, talks about human factors and measurements in paediatric safety. Anne Matlow, Sick kids Toronto talks about the major problem of diagnostic error in children, pointing out that diagnostic mistakes account for 13-20% of adverse events, but are more likely to be preventable and are more likely to cause serious harm or death. Paul Sharek, Stanford discussed medication safety, raising the provocative point that although a great deal of money has been devoted to improving medication safety, medication errors account for 20% of all errors and a much smaller proportion of serous harm.
Thursday, November 25, 2010
Preventable Harm in Hospitalized Patients
Following on from my recent discussion about the use of trigger tools, a paper just published in the New England Journal reports the rate of preventable harm occurring in patients admitted to 10 North Carolina hospitals over a 6 year period. The authors used a validated trigger tool to analyze charts from 100 admissions per quarter.
The results are very alarming; despite a reputation as being a state that is very proactice in efforts to reduce harm, there was no reduction in harm over the study period. For every 100 admissions, there were 25 episodes of harm. It is important to point out that not every one of these episodes caused serious harm. 18% of patients were harmed as a result of medical care. 63% of these episodes were considered to be preventable. Of the harm episodes considered to be preventable, 26% caused permanent damage, were life threatening or caused or contributed to a patient death. overall 2.4% of harms caused or contributed to a patients death.
The most common errors arose from procedure complications, hospital acquired infections and medication errors.
This paper is a wake up call for the patient safety movement; despite much apparent and real progress over the past decade, it is a cause for concern that there has been no significant improvement in patient safety. There are likely many reasons for this; patient safety has not been a research priority, safety always involves a cultural shift within in heathcare which can be very difficult to achieve, and by not involving the younger generation of healthcare professionals, especially at their training stage, we are adding to the difficulty.
The results are very alarming; despite a reputation as being a state that is very proactice in efforts to reduce harm, there was no reduction in harm over the study period. For every 100 admissions, there were 25 episodes of harm. It is important to point out that not every one of these episodes caused serious harm. 18% of patients were harmed as a result of medical care. 63% of these episodes were considered to be preventable. Of the harm episodes considered to be preventable, 26% caused permanent damage, were life threatening or caused or contributed to a patient death. overall 2.4% of harms caused or contributed to a patients death.
The most common errors arose from procedure complications, hospital acquired infections and medication errors.
This paper is a wake up call for the patient safety movement; despite much apparent and real progress over the past decade, it is a cause for concern that there has been no significant improvement in patient safety. There are likely many reasons for this; patient safety has not been a research priority, safety always involves a cultural shift within in heathcare which can be very difficult to achieve, and by not involving the younger generation of healthcare professionals, especially at their training stage, we are adding to the difficulty.
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