Vast majority of medical errors go unreported

Greenbeard

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Jun 20, 2010
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One of the "ten simple rules" for building a smarter, higher quality health system mentioned in another thread was:

Current: "Do no harm" is an individual responsibility. New: Safety is a system property. Patients should be safe from injury caused by the care system. Ensuring safety requires greater attention to systems that help to prevent and mitigate errors.​

A NYT article today serves as a reminder that there's still a long way to go on that front. It's about a recent report from the HHS Office of the Inspector General that found "Hospital employees recognize and report only one out of seven errors, accidents and other events that harm Medicare patients while they are hospitalized." More importantly, errors are shrugged off as isolated incidents (i.e. lapses in individual responsibility of practitioners) with little attention given to addressing the systems that enable them.

“Despite the existence of incident reporting systems,” Mr. Levinson said, “hospital staff did not report most events that harmed Medicare beneficiaries.” Indeed, he said, some of the most serious problems, including some that caused patients to die, were not reported.

Adverse events include medication errors, severe bedsores, infections that patients acquire in hospitals, delirium resulting from overuse of painkillers and excessive bleeding linked to improper use of blood thinners.

The inspector general estimated that more than 130,000 Medicare beneficiaries experienced one or more adverse events in hospitals in a single month.

Many hospital administrators acknowledged that their employees were underreporting injuries and infections that occurred in the hospital, he said. [...]

More often, Mr. Levinson said, the problem is that hospital employees do not recognize “what constitutes patient harm” or do not realize that particular events harmed patients and should be reported.

In some cases, he said, employees assumed someone else would report the episode, or they thought it was so common that it did not need to be reported, or “suspected that the events were isolated incidents unlikely to recur.”

The inspector general found that “hospitals made few changes to policies or practices” after employees reported harm to patients. In many cases, hospital executives told federal investigators that the events did not reveal any “systemic quality problems.”

Organizations that inspect and accredit hospitals generally “do not scrutinize” how hospitals keep track of medical errors and other adverse events, the study said.

The federal investigators did an in-depth review of 293 cases in which patients had been harmed. Forty of those cases were reported to hospital managers, and 28 were investigated by the hospitals, but only five led to changes in policies or practices, the study said.

Preventable medical errors remain a serious problem, though there is now a nationwide effort to address some of the systemic problems that allow many of these errors to occur: the Partnership for Patients.
 
Granny wonderin' if it can be used for orgasyms?...
:eusa_shifty:
Electric pants aim to stop bedsores
15 October 2012 - Could electricity beat bedsores?
Underwear designed to jolt the buttocks with electricity may be able to prevent dangerous open wounds called pressure sores, claim researchers. Sores form when people are stuck in one position for too long, which compresses the skin and cuts off the blood supply. Canadian academics said that in a short trial on 37 people, the mild current mimicked fidgeting and prevented the sores forming. The Royal College of Nursing said sores cost the NHS up to £2bn a year. Pressure sores are a common problem in hospitals around the world as patients are often too ill to get out of bed. Older people are at heightened risk because of poor circulation. Half a million people in the UK develop sores each year.

Regular zapping

Doctors at the University of Calgary tested underwear which placed two pads of electrodes on each cheek. Patients who were unable to move because of a spinal cord injury were zapped with 10 seconds of stimulation every 10 minutes for 12 hours a day. The findings, presented at the Neuroscience 2012 conference, showed that none of the 37 patients developed a sore during the month long trial. The researchers said the device mimicked fidgeting leaving people sitting in a slightly different position.

Robyn Rogers, a research nurse at the university, said: "Pressure ulcers can be terribly debilitating. "Their incidence has not changed since the 1940s, indicating that the current methods of prevention simply are not working. "Our hope is that this innovative, clinically friendly system will eventually make a difference in the lives of millions of people." The researchers said the pants were popular with nurses and patients, however, much larger studies would be needed to test how effective the underwear was at preventing bedsores.

Dr Peter Carter, the chief executive of the Royal College of Nursing, said: "Pressure ulcers, which can be prevented by good skincare, nutrition and regular movement, are not only very painful and distressing, they cost the NHS up to £2bn per year to treat. "The expertise is out there, and good practice in many areas shows that money can be saved, not to mention the distress which can be prevented. "All care settings need to make a concerted effort to make pressure ulcers a thing of the past, and if new technology can help and is cost-effective then nurses will welcome that. "However, this must not be a substitute for having the right number of well-trained staff on a ward."

BBC News - Electric pants aim to stop bedsores
 

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