No one likes to talk about them, the unspoken: medical errors. What are we afraid of? Someone was wrong and needs to be punished. Someone should be sued. Isn’t that the way the course of conversation goes, or we think it will go? But here’s a reality: medical errors occur because we are all human. We NEED to talk about errors that occur, to learn and prevent the same thing from happening next time.
Vice President Joe Biden and former President Bill Clinton spoke at the Patient, Safety, Science and Technology Summit in Irvine California this past weekend to weigh in with healthcare professionals about medical errors and patient safety. The goal: “Zero deaths due to medical errors by 2020”. http://www.beckershospitalreview.com/quality/bill-clinton-joe-biden-weigh-in-on-patient-safety.html
What is a medical error? How often do medical errors happen? Is there anything a family caregiver can do while a loved one undergoes care?
Medical errors are often caused by subtle, difficult to pinpoint “melt-downs” in processes, functions, systems, communications. Medical errors result from assumptions made, misinterpretations of facts and data, limited viewpoints.
All health care providers, family members and patients contribute to the causes. Communications are key and must be valid, concise, and pointed to assure a small misinterpretation of the information available doesn’t become a huge medical error and even accidental death. In medical error review, clinicians are taught they must ask “why” enough times to get to the “root cause” of any error.
Here’s a scenario from the case files that shows just how easily medical errors can happen (facts and names have been altered to protect privacy):
Muriel is visiting her 78 year old mother Mary, who has been in the hospital ICU for the past week. Muriel notices Mom is less alert today and is confused (not her norm), talking about Aunt Audrey visiting. Aunt Audrey has been deceased for the past 8 years. Muriel mentions her concerns to Stacy, her nurse today who has just entered her room to give Mary her medications. Muriel tells Stacy “Mom is confused today. She seems to think my dead aunt visited her today and she isn’t very alert. I had a hard time waking her and by the time I finished my sentence, she dropped off to sleep again”. Stacy tells Muriel that “ICU syndrome” or “ICU delirium” is not unusual, because Mary has been having a hard time getting a good night’s rest in the ICU. “It happens quite often, and besides she’s 78…she’s likely to be confused”, she reasons with Muriel.
While the nurse’s explanation may be a reason, Muriel’s hunch is that there is something more brewing. After all, she reasons, Mom has been here for a week and she hasn’t been confused before today. She’s different today…she’s using a lot of extra muscles in her chest to breath and seems to be breathing faster. So Muriel takes some time to think more about what else she notices different with her mom. She sees that her mom is having a very hard time eating her lunch with the face mask on and notices that her mom seems much more tired after taking a few bites of food. She observes that Mom is resting her head back on her pillow while she chews and swallows. Muriel makes a note about her concerns and plans to talk to the doctor about it when she comes to make her rounds.
In the meantime, the oncoming nurse visits with the day shift nurse at Mary’s bedside and they discuss Muriel’s earlier concern about Mary’s breathing. They review Mary’s case and ask Mary how she is feeling as the day has progressed. Mary says she is really tired. Joanne, the nurse coming on duty listens to her lungs and notices that her lungs aren’t as clear as yesterday. Joanne makes a note and later reports to Dr. Johnson about her findings, and also shares the patient’s and daughter’s concerns.
Dr. Johnson decides to get a chest x-ray and blood work and visits Mary in her room. She tells Muriel and Mary that “it looks like Mary has pneumonia. I am concerned about this x-ray because it is now showing shadows that weren’t there just two days ago when we did the last x-ray. I am also concerned that the blood gases show you’re retaining carbon dioxide, Mary, which can cause confusion. We need to lower your oxygen dose and monitor you closely to see how things improve. I am going to have a Speech Therapist visit to do an evaluation. I am concerned that you may be aspirating. Aspiration occurs when food or liquid goes into the lungs instead of down your throat when you chew and swallow. ”
The speech therapist visits a short time later and asks questions and has Mary chew and swallow several different consistencies of foods and liquids. Mary does fine with her evaluation. There is no coughing or choking with any of the food or fluid. After reviewing her findings with Dr. Johnson, Dr. Johnson reviews her concerns with Mary and Muriel. “I suspect that the force of the oxygen you have been using has caused some of the food and fluid you are eating to be blown back into your airway as you chew and swallow, Mary. You are receiving a high flow of oxygen through your mask and it may be pushing food and fluid into your lungs. From now on, we will switch your oxygen to a very low flow while you eat.”
Medical errors like this occur due to several small failures, or flaws in assumptions, mistakes in observations and failed processes. Individually, the failures aren’t big enough to cause an accident, but combined can result in an error. Such errors can ultimately result in accidental death.
Patients and their families can have a safer experience with the health care system by being involved and informed about their treatment. Improving patient safety requires constant communication between the institutions and people caring for patients, as well as patient and their families. Patients often are too ill (and often temporarily confused as Mary was) to advocate for their own needs effectively. Everyone has a role in patient safety, and everyone will benefit from its successes.
- If you or a loved one is undergoing treatment, ask questions. Write down your questions before appointments, or in preparation for doctors rounds while in the hospital.
- Seek additional information from reliable websites about illness or conditions that affect you or a loved one. Websites produced by the United States government end in .gov and include educational information that has been written by and edited by health experts. See websites that are also written by credible health care organizations, documented health care experts, and hospitals.
- Research options and treatment plans. Gain some understanding and then discuss issues that arise with your health care providers.
2. Work with your team.
- Share your health history with your health care team.
- Pay attention. If something doesn’t seem right, call it to the attention of your team members.
- Discuss any concerns about safety or potential errors with your health care providers. Follow your instincts. You know your loved one best.
3. Follow the treatment plan developed and agreed upon by you, your loved one, your doctor, and your team.
- Be sure you receive instructions at the time of the visit and get it in writing to refer to later.
- Take medication exactly as it was prescribed.
- Use the treatments and supplies provided to you as you were instructed.
- Report anything unusual to your doctor and team.
See more great information about Patient Safety and reducing Medical Errors at National Patient Safety Foundation (http://www.npsf.org/).