“For all of its strengths, our health care system still is plagued by avoidable errors. ” -President Bill Clinton The issue of medical error is recognized as a very serious U. S. healthcare concern in terms of avoidable patient death and injury, achieving efficacious treatment, and in controlling the costs. The prevention of medical errors may seem to be a relatively simple task and with recent awareness, some improvements have been accomplished.
However, the search for reasonable, acceptable, and more effective remedies and countermeasures continue with force. Attention to medical errors escalated over eight years ago with the release of a study from the Institute of Medicine (IOM), To Err is Human, which found that between 44,000 and 98,000 Americans die each year in U. S. hospitals due to preventable medical errors. Hospital errors rank between the fifth and eighth leading cause of death, killing more Americans than breast cancer, traffic accidents, or AIDS.
Serious medication errors occur in the cases of 5 to 10 percent of patients admitted to hospitals. These numbers may understate the problem because they do not include preventable deaths due to medical treatments outside of hospitals. Since the release of the IOM study, there has been greater focus on the quality of healthcare provided in the U. S. Quality experts agree that one of the most common causes of errors is the medical system itself, not the individuals functioning within the system.
The publication of the IOM report triggered substantial public and private sector activity, including the formation of the National Patient Safety Foundation by the American Medical Association; the creation of a non-punitive sentinel events reporting system by the Joint Commission for the Accreditation of Healthcare Organizations; and the establishment of new public private partnerships by the Veterans Health Administration and similar agencies. Still, experts agree that there is much more work to do. For example, fewer than 3% of hospitals have implemented computerized drug ordering systems which one study found to reduce medication errors by 86%.
In a December 2002 Kaiser Family Foundation survey, only 5% of physicians identified medical errors as a top health care concern. [1] Shortly after the release of the 2000 IOM report, Congress gave $50 million to the U. S. Agency for Healthcare Research and Quality for research into the causes and prevention of medical errors. Controversy over how to address medical errors has since entered into debates, including whether the federal government should restructure the current medical malpractice system.
States have also been a part of this debate, as several now have mandatory error reporting rules and statutes with a patchwork of differing requirements. Although the numbers and the statistics are out there, the American public still does not have a full grasp of the importance of this healthcare problem. Granted, the issues of illness, accidents, and disparities will always be of significance; yet, the monies being spent on medical errors each year ($29 billion) could be placed in to programs preventing and treating the unavoidable.
As stated previously, the Department of Veterans Affairs has implemented computerized programming that aids in preventing medical error. They have created an error reporting system, established four Centers of Inquiry for Patient Safety, and began to use barcode technology to reduce medication errors. These are prime examples of what the 97% of U. S. hospitals should be executing. However, the medical media is not conveying that such changes are vital to the improvement and growth of the healthcare system.
One of the most accessible ways to promote the imperativeness of medical error in healthcare is through the workforce and employer insurance plans. Some of the nation’s biggest companies, i. e. General Motors, are working with the private sector and have created plans that make safe medicine a top priority of the health insurance provided by the companies and promote workers to visit hospitals with first-rate records. In working with the Leapfrog Group and similar organizations, quality experts believe that the act of publicly releasing information has improved the quality of healthcare for employees, in general.
The dissemination of hospitals’ performance information by the members to their enrollees has reinforced the acts and efforts to improve safety and quality. [2] The last aspect in increasing public awareness involves changing the mindset of the people from individual problem to systems problem. Most people believe that medical errors are the result of the failures of individual providers. The public believes that possible solutions to medical errors are to keep health professionals with bad track records from providing care and give better training to health professionals. The IOM report stated that it is a systems problem.
They emphasized that most of the medical errors are systems related and not attributable to individual negligence or misconduct. The key to reducing medical errors is to focus on improving the systems of delivering care and not to blame individuals. Health care professionals are simply human and, like everyone else, they make mistakes. Research has shown that system improvements can reduce the error rates and improve the quality of health care. A 1999 study indicated that including a pharmacist on medical rounds reduced the errors related to medication ordering by 66 percent, from 10. 4 per 1,000 patient days to 3.
5 per 1,000 patient days. The specialty of anesthesia has reduced its error rate by nearly sevenfold, from 25 to 50 per million to 5. 4 per million, by using standardized guidelines and protocols and standardizing equipment. [3] The U. S. healthcare system must not cease in its efforts to reduce and control medical errors. With countless lives lost, injured, and indefinitely changed daily, the measures to counter these avoidable acts cannot go unnoticed. From JCAHO’s sentinel events policy to the AHRQ’s surveys, the establishment of national goals of reducing the number of medical errors must remain at the forefront of the system.
References Author unspecified. (2008). Health News Index – November/December 2002. Retrieved October 25, 2008, from The Henry J. Kaiser Family Foundation, website: http://www. kff. org/kaiserpolls/20030102a-index. cfm Galvin, R. S. , et. al. (2005). Has The Leapfrog Group Had An Impact On The Health Care Market? Health Affairs, 24, (1), 228-233 Migdail, K. J. , (2008). Medical Errors: The Scope of the Problem. Retrieved October 25, 2008, from Agency for Healthcare Research and Quality, website: http://www. ahrq. gov/qual/errback. htm.
[1] Author unspecified. (2008). Health News Index – November/December 2002. Retrieved October 25, 2008, from The Henry J. Kaiser Family Foundation, website: http://www. kff. org/kaiserpolls/20030102a-index. cfm [2] Galvin, R. S. , et. al. (2005). Has The Leapfrog Group Had An Impact On The Health Care Market? Health Affairs, 24, (1), 228-233 [3]Migdail, K. J. , (2008). Medical Errors: The Scope of the Problem. Retrieved October 25, 2008, from Agency for Healthcare Research and Quality, website: http://www. ahrq. gov/qual/errback. htm.