Health care professionals work to reduce preventable errors
Posted June 4
Updated June 10
Chapel Hill, N.C. — The landmark report by the Institutes of Medicine in 1999 titled “To Err is Human” showed preventable medical errors totaling 98,000 per year.
Today, studies such as those in the September 2013 issue of the Journal of Patient Safety claim a total as high as 440,000. That total would make preventable medical errors the third leading cause of death in America behind heart disease and cancer.
In November of 2000, 15-year-old Lewis Blackman was in a teaching hospital in Georgia for elective surgery to straighten his breast bone. While in the hospital he died from the adverse effects of a medication he was given.
Helen Haskell, Blackman’s mother, said no one recognized that her son was developing complications.
“No one ever rescued him, and no help ever came,” Haskell said. “So he died in a hospital bed without a doctor ever having been called."
Haskell is now a national advocate for patient safety and health care quality.
“A big problem that happened to Lewis was lack of teamwork,” Haskell said, “So nobody really talking to each other.”
Dr. Allen Mask, WRAL health expert, visited UNC’s pediatric intensive care unit where teams are working to reduce preventable medical errors.
“Taking to each other” is something that happens every morning at the unit. As different specialists discuss each patient’s case, doctors like Dr. Benny Joyner, of the pediatric intensive care unit, also lead surprise training exercises to prepare staff members.
Example cases such as a baby going into septic shock push the team of care providers to work together through the symptoms to save the baby’s life.
“The big focus has been recognizing that it’s a systems issue,” Joyner said. “We’re really trying to remove the blame from an individual provider and saying, 'How can we make the system more efficient? How can we work toward delivering better, safer, more efficient care?'”
These practice exercises give the team a chance to discuss what went right and what could be done better.
The focus, Blackman’s mother says, must be on the patient, not hospital hierarchies.
“It’s really important for health care providers to understand that patients are people,” Haskell said. “Anything that affects that patient affects a lot of people.”
Mask said there are steps patients and their family members can take to lessen the chance of medical errors while helping make physicians and nurses more mindful and accountable:
- Ask or go online to check the hospital’s infection or medical complications rates
- Look up the hospital’s rating on Consumer Reports
- Talk to the physicians and nurses about what they do to minimize errors on their cases
- Ask how physicians and nurses are improving communication and teamwork