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Posts tagged with "medical error"

Patient Safety, A First Hand View

It is a known fact that more people die annually from medical error, in both in-patient and out-patient healthcare settings, than die from motor vehicles accidents, breast cancer or HIV. Nearly 100,000 reported medical errors occur each year. As an e- patient, there are actions that you can take to insure the safety of your care. They include:
•Do not assume anything! Make sure that all health professionals involved in your care have all the important health information about you. Talk with them about what additional data they might need.

•Ask questions. If you have a test, insist on getting the results. If you are given medication be sure to ask what it is; what it is for; is it the right dosage. If there are pills you do not recognize, do not take them until you talk with your doctor. This is your right.

•Learn about your conditions and treatments. Discuss your healthcare with your doctor, nurse practitioner, physician assistant and/or pharmacist. Check the Internet to see what information you can find. A few of the helpful, unbiased web sites include:

1. Google or Bing search for the most general compilation of available data.

2., or institutions sites such as or for general information on a variety of health conditions.

3.,  and,  for the most comprehensive health information in one place.
4. , a website of the Joint Commission on Accreditation of Healthcare Organizations that provides extensive information on hospitals, sorted by geographic location and including accreditation criteria, special citations and programs.

I have been away from this blog for a while because I spent some real time as a patient, having hip replacement surgery. Although I had complete confidence in my surgeon, I made sure that I fully understood the parameters of my problem, the solution, and the recovery by asking the right questions and conducting my own research to find answers to all of my concerns. Much to my surprise, my hospital experience completely changed from previous in-patient encounters. Everyone diligently washed their hands at one of the antiseptic soap dispensers located in patient rooms and on every floor. That alleviated my biggest fear of staph and mersa infection so prevalent in the hospital environment.

Another concern was the potential for a fall as I knew that the hip replacement would incapacitate my movement for a while. However I was told to absolutely call for help when I wanted to get out of bed, and the nurses and aides were most pleasant about assisting me. The last time I was in the hospital after surgery the nurse told me I had better learn to get out of bed myself and not bother them. What a turnaround in patient safety!

Because I am familiar with the dangers of medication error, both in the hospital and at the rehab, I also questioned every IV and oral medication that I was given to be sure that the right medication in the right dosage for me was what I received. No one took offense. They appreciated my caution and understanding.

Patient Safety is not an easy goal to accomplish in the stressful healthcare setting. Mistakes are still made. However when an e-patient opts to become an integral part of the healthcare team many unpleasant medical errors can be averted.

Dealing with Guilt, Isolation and Fear when Adverse Medical Events Happen

I recently attended a forum entitled Medical Error: The Power of Apology, Action and Forgiveness. Paul Levy, CEO of the Beth Israel Deaconess Medical Center in Boston (BIDMC) led off the program with a discussion of his initiative to make public all occurrences of preventable medical events at the BIDMC. Levy pointed out that hospitals are the fourth ranked health hazard in the nation! He recommended a “laser-like” focus on quality that engages all stakeholders in healthcare that might help ameliorate this outrageous statistic.

Dr. Tom DelBanco, M.D., Professor of General Medicine and Primary Care, at Harvard Medical School was the lead speaker at this forum. For over 30 years Dr. DelBanco was Chief of the Division of General Medicine and Primary Care at the BIDMC. He is also a founding Chair of the Picker Institutes in the USA and Europe, an organization that documents patient experiences with care and works with patients to improve health services.

Dr. DelBanco reminded us that patients or care givers advocating for patients who have been injured in the health care system often suffer guilt, fear and isolation when an adverse event occurs. These emotions are equally shared by the doctors and nurses who have been involved in medical errors. Dr, DelBanco pointed out that disclosure and communication could effectively help resolve the emotions that surface after these occurrences. His talk was followed by two patient presentations whose horrific experiences with medical errors were a powerful reminder of how things can go wrong without intent or provocation and how those wrongs could have been made tolerable if the doctors had admitted their error, showed compassion and maintained communication with their patient.

As an individual whose career has been devoted to understanding communication, teaching communication skills and using communication tools, I see a unique opportunity for healthcare institutions to attack the syndrome of emotions resulting from an adverse medical event by: (1) implementing high standards-based quality measures that help to insure that everything humanly possible is in place to avoid these medical errors and (2) providing training to healthcare professionals in the elements of communication. In times of stress, when guilt, isolation and fear overtake the individual who realizes that a mistake has been made, the tendency is to avoid all contact with the problem.

In the digital era we run the additional risk of increasing the communication gap between patients and doctors as one-on-one interactions are replaced with virtual interactions. Open communication will not come about by itself. A deliberate and thoughtful plan is needed to help healthcare staff learn how to explain these situations and talk through these issues with patients. Encouraging those difficult conversations will go a long way in making everyone feel better about themselves and the situation.