March 15, 2008
National Patient Safety Goals: Systems to Reduce Medical Errors
by Marin Granholm, MD
What do we think of when we think of medical errors? Many of us might think of dramatic examples we've seen or heard in the news, such as wrong-site surgery, and wonder how such a major error could happen.
Perhaps we chalk it up to incompetence of the surgeon involved, and vow never to attend that hospital. It turns out, however, that there is no avoiding "that" hospital: it has been estimated that as many as 98,000 people die annually in U.S. hospitals due to medical errors.
When the causes of these errors are studied, it is found that they result not from individual error, but from the complexity of modern-day health care. Errors can occur anywhere in the health care system, from hospitals to patients' homes, and they can involve steps as complex as medical diagnosis or as simple as whether a patient receives the correct diet.
The field of medicine is learning, however. We have had some useful examples set for us in managing complex systems. Getting on a plane used to be a lot more dangerous before the modern system of checks and balances was instituted; now flying is considered much safer than driving. Professionals in medicine have been instituting similar checklists, referred to as National Patient Safety Goals, to double check areas at risk for error and decrease the numbers of medical errors.
National Patient Safety Goals have included improving the accuracy of patient identification, improving the effectiveness of communication among caregivers, improving medication safety, reducing the risk of hospital-acquired infections, reducing the risk of patient falls, and a preoperative universal protocol that verifies that everything is in place and correct prior to every surgery.
Important new goals for 2008 include rapid recognition and response to changes in a patient's condition, and reducing the risks associated with blood thinning medications.
YKHC is again joined leading health care organizations around the world in marking 2008's National Patient Safety Awareness Week, March 3-7. This year's theme, "Patient Safety: A Road Taken Together," emphasizes that in order for health care systems to work well, providers, staff, patients and families must all work together as a team. This theme also builds on YKHC's mission of "Working together to achieve excellent health."
During this week, an information table was set up at the Bethel hospital lobby during the noon hour for both patients and employees to receive help filling in their Medication List sheets, talk with a Pharmacist to review medication prescriptions, and receive all types of education on patient safety.
The single most important way you can help to prevent errors is to be an active member of your health care team. Ask your provider questions, and make sure you understand the answers. See the sidebar on the next page for a list of what you can do to help prevent medical errors as an active member of your own healthcare team.