subject: Medical Errors, Blunders and Foul-ups; Where will the buck stop? [print this page] Medical Errors, Blunders and Foul-ups; Where will the buck stop?
The public safety issue of hospital mistakes being the fifth leading cause of death in the United States is once again gaining some notoriety, but this crucial subject is not exactly making headlines. However, there does seem to be more chatter about it in the "blogosphere". It seems that since Medicare policy makers decided to refuse payment for medical and nursing blunders, all of the third party payers of health care services, such as state Medicaid systems and private carriers, are following suit. On the surface, one might be glad of this change because until this year, hospitals would actually cash in on substandard care. Hurting people was actually more profitable that healing them. Although we can be certain that hospital executives for the most part were not making conscious decisions to allow untoward events to occur in order to increase their revenue, many have certainly demonstrated a lackluster motivation for taking effective preventive action. Therefore, it seems logical to assume that the prospect of eating the higher costs of hospital-induced complications would motivate the governing bodies to achieve a serious clinical transformation.
On the other hand, it is not so clear that the motivation for denying payment for iatrogenic illness and injury is prevention for public safety. It seems more like a bandwagon that government agencies and insurance companies are jumping on to avoid paying large chunks of hospital bills. Moreover, in the new upcoming avalanche of payment denials, the third party payers will have to accuse the provider of negligence by identifying the unexpected complication as the result of a "never event" and satisfy the burden of proof against a vigorous defense. Each of these challenges will take more than a decade because of the several layers of administrative appeals that the parties must climb through before going to court. Therefore, it is more than likely that this new wave of financial pressure is going to be ineffectual.
Consequently, in order reduce the onslaught of wrongful death and catastrophic injury arising from hospitalization; we have to become more cognizant of the meaning of terms like "hospital mistakes" or "medical errors". We have to understand exactly what is going on in the hospitals that repeatedly cause the same blunders in every facility in America. The answer is clear; the physical structure, management style and method of delivery are similarly flawed, which causes the same mishaps to keep reoccurring. This situation is comparable to the defects in the Boeing 737 aircraft, which recently caused the cancelling of hundreds of commercial flights.
However, hospitals must remain open and financially viable to serve the greater good. For most families the hospital is an integral part of the survival of our loved ones. Therefore we need to understand these "never events" that are always happening and their root causes.
Therefore, we shall explore these "always happening never events" as follows:
Errors of Commission: overt acts that deviate from accepted standards such as:
Invasive blunders
Traumatic transfers
Misapplication of forceps
Administering harmful medication or treatment
Withholding medication or treatment
Physical abuse
Errors of Omission: failure to provide services resulting in an adverse event:
Failure to take a proper history
Failure to report changes in clinical condition
Failure to maintain safety protocols
Failure to maintain pressure ulcer prevention
Failure to wash hands between patients
Failure to make risk assessments
Risk Factors Predisposing to Medical Errors
New Technology
Staffing Shortage
Teaching Hospital
High Patient Acuity
Patients with Mental Status Deterioration
Staff Members in ill health
Medical specialization "It's not my job"
Poor listening skills
Arrogance
Root Causes
Poor Communication
Emergency Room Overcrowded with Long Waiting Times
Non-Disclosure of Risks to Patients and Family
Chronic Cash Flow Deficit
Operating Rooms Closed at Night
Ineffective Nurse Recruitment
Poor Labor Relations
Equipment and Building in Disrepair
In conclusion, we can now see clearly that intervention for prevention is not about reward and punishment. It is bout clinical transformation. People run every aspect of the system from top to bottom, so it is the hospital staff who need to change their already-always ways of doing things by changing their familiar ways of being.
