Ofri says the reporting of errors — including the "near misses" — is key to improving the system, but she says that shame and guilt prevent medical personnel from admitting their mistakes. "If we don't talk about the emotions that keep doctors and nurses from speaking up, we'll never solve this problem," she says.
Broadly speaking, the progress is the result of a crusade that dates back at least to 1990s, when the Institute of Medicine released “To Err Is Human,” a seminal report suggesting that nearly 100,000 people were dying each year because of preventable medical mistakes. Over time, researchers learned more about why these errors were so common and started developing methods for avoiding them. Probably the most famous of these was the introduction of checklists, like the ones that airplane pilots use before takeoff, for making surgery safer.
The Joint Commission, which the government relies on to accredit most hospitals, rarely withdraws its approval in the face of serious safety violations.
I walked out of the NICU with my laptop in hand, feeling grateful for people like her who keep our children safe and the rest of us in line.
Few things are deadlier than doctors’ screw-ups. NASA’s chief toxicologist calculated in 2013 that medical error kills between 210,000 and 440,000 Americans each year. Only heart disease and cancer have a higher body count.
Some progress has been made.
It’s not just the medical physicians that are affected by burnout, it is the entire medical team. A report published by the Journal of General Internal Medicine concluded that 41.5% of nurse care managers, 32% of licensed practical nurses, and 35.7% of administrative clerks suffered from burnout.
Doctors can adopt many safer prescribing practices, while doing everything they can to make sure their patients have the best possible pain care.
Hotel rooms have occupancy limits, as do elevators, and even taxi cabs in New York City, but few laws in the United States regulate or even monitor the number of patients that any one hospital nurse can be responsible for at a given time.
Medicine has changed before, after all. When it did, government policy played a role. But much of the impetus came from inside the profession. Doctors helped change other doctors. For the past decade or so, a loose group of reformers has been trying to do precisely this. They have been trying to figure out how to improve health care while also holding down the growth in costs.
Much like the airline industry has improved its safety record, patient safety in the operating room has also improved. Recognizing that humans make mistakes, specific processes are now part of the operating room routines meant to minimize individual errors and a culture of open communication with all members of the operating room team allow for anyone to voice issues of concern. These steps have gone a long way to improving patient safety.
A new study finds that 40 percent of physicians in hospitals report that, at least once a month, they took on more patients than they could safely handle. The results suggest that hospitals need to evaluate doctors' workloads and create standards for safety.
There are more than 50 in-flight medical emergencies a day on commercial airlines — or one for every 604 flights, according to a study published in 2013.
What are the odds that two emergencies would occur on the exact same flight, above the Atlantic Ocean and hours from the nearest airport?
The United States is a nation of patients. More than 300 million Americans — 95 percent of us — encounter the nation’s health care system at least once in the space of five years. It’s essential that every health care encounter is safe and free from harm. Sadly, that isn’t the case.
Kiani is also the founder of the non-profit Patient Safety Movement Foundation, with a mission to drastically reduce the more than 200,000 preventable patient deaths that occur in U.S. hospitals every year from medical errors and hospital acquired infections (HAI).
If you aren’t alarmed enough that our country is burying a population the size of Oakland every year, try this: you are paying for it.
A time-out, particularly a time-out called by a nurse, is a fairly recent invention which turns traditional hospital custom and practice on its head. It is just one of many innovations reviewed and refined at meetings of a hospital task force with the lofty designation Performance Improvement and Patient Safety Committee. More informally, PIPS.
In a field that has been dangerously slow to adopt standardized care practices, one influential obstetrician has pushed things forward with common sense.
Being assertive is not about being “the patient from hell.” It is about filling your role as the safety net of the safety culture. Whether it’s asking that a thermometer be checked or making sure that the surgeon has marked the correct leg for amputation, being assertive is often the last guard rail before being hurt.
Be assertive and help yourself, the next patient and the hospital industry be safe.
Health care has been thinking about medical errors for nearly 20 years, starting with the Institute of Medicine’s 1999 report “To Err is Human.” This and other work across the country have correctly shed light upon such medical errors as amputation of the wrong limb, inpatient adverse drug events and hospital-acquired infections, and we have made great strides in preventing these errors. However, most patient care occurs outside of the hospital, and little attention has been paid to identifying and addressing patient safety in this setting.
Would my white lab coat be better put to use when I carve the Christmas roast than when seeing patients?
After all, we know that these coats can be covered with pathogens, including drug-resistant ones, which may be transmitted to patients. They are cleaned infrequently: In a survey of physicians, nearly 58 percent said they laundered their white coats monthly or never. Less than 3 percent washed them daily or every other day. What is the harm in adopting a "bare below the elbows" policy for health care professionals — as has been done in the United Kingdom — to reduce the chance of transmission?
Emerging data support minimum nurse-to-patient ratios, but hospital administrations are reluctant to adopt them.
Health care will be safer — and patients' goals will more often be met — if we partner with patients and their loved ones, offer them the opportunity to share their ideas for improving care and listen and respect their wisdom.
Health-care innovations aren't limited to drugs and devices. Experts increasingly are adopting new ways to treat patients that studies show are better at healing the sick, preventing disease, improving patients' quality of life and lowering costs.
PSAN is a coalition of individuals and organizations consisting of patients who have been medically harmed, their loved ones, and concerned advocates. With a unified voice we focus solely on and with patients to raise awareness and to create accountability, transparency and safer healthcare.
The Patient Safety Movement is connecting people, ideas and technology to confront the large scale problem of more than 200,000 preventable patient deaths in U.S. hospitals each year by providing actionable ideas and innovations that can transform the process of care, dramatically improve patient safety and help eliminate patient preventable deaths. It is doing this one solution, one commitment, one hospital, one act of kindness and love, and one patient at a time. The movement is breaking down silos between hospitals, medical technology companies, patient advocates, patients, the government and all the stakeholders affected in healthcare -- all of us. Together we are pushing toward ZERO preventable deaths by 2020.
The Congress developed and enacted the Patient Safety and Quality Improvement Act of 2005 (Act) in response to the Institute of Medicine(link is external) report, To Err Is Human(link is external), which sparked national concern over the number of preventable medical errors that were occurring.
The Society for Participatory Medicine is a 501(c)(3) not-for-profit organization devoted to promoting the concept of participatory medicine, a movement in which networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners.
We are a network of 100+ children’s hospitals who share the vision that no child will ever experience serious harm while we are trying to heal them.
The Center for Patient Protection is the champion of patients and families struggling with medical errors and related emotional harms, and of capturing their experiences to improve patient safety for everyone.
Voices for Safer Care serves as a forum for health care professionals, patients and others who are committed to ending preventable harm, improving patients’ outcomes and experiences, and reducing waste in health care.
Consider us a comprehensive resource for information about faulty medical devices, FDA alerts, and any other information about dangerous consumer products.
At ECRI Institute, we take pride in being a place where theory and practice combine to produce safer, more effective healthcare. Our staff is also bonded by a commitment to objectivity and to serving our members.
Health Care Without Harm (HCWH) is an international nongovernmental organization (NGO) that works to transform health care worldwide so that it reduces its environmental footprint, becomes a community anchor for sustainability, and a leader in the global movement for environmental health and justice.
IHI is a recognized innovator, convener, and generous leader, a trustworthy partner, and the first place to turn for expertise, help, and encouragement for anyone, anywhere who wants to profoundly change health and health care for the better.
This blog is about patient safety, medical malpractice, staying healthy, and preventing future errors. Help & empower someone else, Teach a lesson, Bear witness, Build our community.
Patrick Malone is a leading medical malpractice attorney and patient safety advocate. He is based in Washington, D.C., and practices throughout the mid-Atlantic region, including Maryland, northern Virginia and the District of Columbia. Malone represents seriously injured people in lawsuits against hospitals, doctors, drug manufacturers, government agencies, and insurance companies. He also speaks publicly to patient groups, health care providers and others about improving the safety of our health care system.
To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.