Patient safety: To do no harm

Abstract

TO THOSE OF US IN health care who believe we practice as Hippocrates advocated, it is shocking that we are, in fact, harming patients. The Institute of Medicine estimates that 44,000 to 98,000 Americans die each year from preventable medical errors. In response, the Business Roundtable (BRT) initiated a new program, The Leapfrog Group, to encourage employers to reward hospitals that implement major safety improvements. The Leapfrog Group is a consortium of approximately 60 members who provide health benefits to over 20 million Americans and spend over $40 billion on health care each year. These employers have agreed to base their purchases of health care on rigorous patient safety measures. They have identified those safety measures as (1) computerized physician order entry, (2) evidence-based hospital referral, and (3) intensive care staffing by physicians trained in critical care medicine. It has been estimated that at least half of adverse reactions to medicines are the result of medical errors, and some statistics suggest that medical errors are the eighth leading cause of death among Americans. This is staggering news. It has also been sensational news. The Chicago Tribune ran a 3-part series on the problem of medical errors, and if you believed the titles, attributed much of the problem to nurses. The titles were “Problem Nurses Escape Punishment,” “Nursing Accidents Unleash Silent Killer,” and “Nursing Mistakes Kill, Injure Thousands.” The articles discussed what the author perceived as lax discipline by some boards of nursing, information on the misuse of infusion pumps that did not have safeguards built in place to stop the free flow of intravenous fluids, and errors that had occurred when nurses were inadequately educated or overwhelmed because of staffing shortages. There were kernels of truth in the series of articles. No one would disagree that there is a problem—with some medical devices and the conditions under which some nurses across the country function each day. However, patient safety is a much broader issue than just nursing. It involves physicians, pharmacists, nurses, medical devices, and most of all, the systems under which all these persons must perform. As has been recognized, one of the most common errors involves medication errors. One of the most common causes of medication errors has been identified as errors in prescribing or filling prescriptions. This is the reason that the Leapfrog Group has identified computerized physician order entry as one of the 3 criteria to use to determine health care services for their employees. One hospital reported decreasing the serious medical error rate by 55% with only minimal technical support and 80% with an advanced technology. Other causes of medication errors include incomplete patient information, confusion of drugs with similar names, lack of appropriate labeling, and environmental factors that distract health professionals. Admitting overflow patients to a unit that is not routinely assigned to that type of patient has also been mentioned as a problem because of the