HOW SAFE IS HEALTHCARE DOCUMENTARY

HCA/220 - THE LANGUAGE OF HEALTH CAREINSTRUCTOR: JUDY JEAN

MAUREEN PELTON

DECEMBER 16, 2013

http://www.youtube.com/watch?feature=player_detailpage&v=6q38tAkmJs8

http://www.youtube.com/watch?v=6q38tAkmJs8

PREVENTABLE ADVERSE OUTCOMES ARE COMMON IN HEALTH CARE

THERE WERE TWO LARGE SEMINAL STUDIES:

NY STATE IN 1984

COLORADO AND UTAH IN 1992

KEY RESULTS:

MEASURE NY UT &

CO

PREVENTABLE ADVERSE EVENT RATE 2.1%

1.5%

% THAT CONTRIBUTED TO DEATH 13.6%

8.8%

Types of medical errors: Diagnostic errors

Error or delay in diagnosis

Failure to use appropriate test

Failure to respond to result of test

Treatment errors

Procedural technical error

Medication error

Delay in treatment

Inappropriate care

Preventive

Failure to provide preventive treatment

Failure to monitor patient

BETTER UNDERSTAND THE TYPES OF ERRORS HERE IS AN EXAMPLES OF THE

COMMON TYPES OF ERRORS

ERROR IN DIAGNOSIS

50 YR. BM ADM FOR SPINE FUSION

AWOKE FROM SURGERY WITH

PARAPLEGIA

DX TRANSVERSE MYELITIS

TRANSFERRED TO AMERICAN

HOSPITAL

DX A

CUTE SPINAL CORD CVA

FAILURE TO USE APPROPRIATE TEST

72 YR. WF WITH UTI

ON THE NEXT DAY, SHE BECAME SUDDENLY WORSE

TRANSFERRED TO ICU

COVERING DOCTOR CHANGED ANTIBIOTICS

ORDERED GENTAMICIN

DID NOT ORDER LEVELS

ONE WEEK LATER SHE HAD ACUTE RENAL FAILURE

CHART REVIEW - FAILURE TO CHECK LEVEL

FAILURE TO RESPOND TO RESULT OF A TEST

45 YR. WM ADM FOR LAP NISSAN FUNDOPLICATION

POST-OP, HAD DIFFICULTY RESUMING DIET

CXR SHOWED FREE AIR UNDER DIAPHRAGM, PNEUMOMEDIASTINUM

PT. DISCHARGED WITH MEDICINES FOR PAIN AND NAUSEA

RETURNED THREE DAYS LATER WITH MEDIASTINITIS

FOUND TO HAVE ESOPHAGEAL LACERATION ON SURGERY

PROCEDURAL TECHNICAL ERROR -OPERATION

PROCEDURAL TECHNICAL ERROR - OPERATION

56 YR. WM ADM FOR HERNIA REPAIR

DURING SURGERY, RIGHT INGUINAL HERNIORRHAPHY PERFORMED

UPON AWAKENING, PATIENT SAYS THAT LEFT HERNIA WAS PROBLEM

UPON REVIEW, IT WAS DETERMINED THAT SURGERY WAS DONE ON WRONG SIDE.

PROCEDURAL TECHNICAL ERROR - OTHER PROCEDURE

40 YR. WM BROUGHT TO THE ER IN CARDIAC ARREST

PT. RESUSCITATED, THEN REQUIRED INTUBATION

THE INTUBATION WAS PLACED IN ESOPHAGUS

PT. DETERIORATED AND REQUIRED REPEAT RESUSCITATION

CHART REVIEW SHOWED THAT THE ERROR WAS THE CAUSE OF THE SECOND ARREST

DELAY IN TREATMENT

56 YR. WF WITH ATYPICAL CHEST PAIN

ER WAS BUSY, SO SLOW TO GET INTO ROOM

MD DID NOT SEE IMMEDIATELY

EKG SHOWED ACUTE MI

THERE WAS DELAY IN PROVIDING THROMBOLYTIC

INAPPROPRIATE CARE

24 YR. WF SEEN FOR NASAL CONGESTION

DX AS UPPER RESPIRATORY INFECTION

RX AMOXICILLIN FOR THE URI

LATER THAT DAY, HAD SHORTNESS OF BREATH

IN ER, FOUND TO HAVE ANAPHYLACTIC REACTION

CHART REVIEW SHOWED UNNECESSARY ANTIBIOTICS LEAD TO REACTION

FAILURE TO PROVIDE PREVENTIVE CARE

TD IS A 70 YR. WF FOR HIP REPLACEMENT

THE SURGERY WAS UNEVENTFUL

3 DAYS POST-OPERATIVELY, SHE DEVELOPED SHORTNESS OF

BREATH.

ABG SHOWED SIGNIFICANT HYPOXIA

CT SCAN SHOWS PULMONARY EMBOLI

CHART REVIEW - NO VTE PROPHYLAXIS

FAILURE TO MONITOR PATIENTFAILURE TO MONITOR PATIENT

76 YR. BF ADM WITH HIP FRACTURE AND ATRIAL FIBRILLATION

STARTED ON SEVERAL MEDICINES TO SLOW THE HEART

HIP FRACTURE REPAIRED WITHOUT DIFFICULTY

IMPROVED AND TRANSFERRED TO REHAB FLOOR

NURSES DID NOT MONITOR HEART RATE

AFTER THREE DAYS, SHE HAS SYNCOPE

FOUND TO HAVE PROFOUND BRADYCARDIA

CONCLUSION

MEDICAL ERRORS ARE BOTH

COMMON

VARIED

UNDERSTANDING IS NECESSARY FOR IMPROVEMENT

REFERENCES1BRENNAN, T.A., LEAPE, L.L., LAIRD, N.M., ET. AL., "INCIDENCE OF ADVERSE EVENTS AND

NEGLIGENCE IN HOSPITALIZED PATIENTS. RESULTS OF THE HARVARD MEDICAL PRACTICE

STUDY I", NEJM 324 (1991), PP 370-376.

2LEAPE, L.L., BRENNAN, T.A., LAIRD, N.M., ET. AL., "THE NATURE OF ADVERSE EVENTS IN

HOSPITALIZED PATIENTS. RESULTS OF THE HARVARD MEDICAL PRACTICE STUDY II", NEJM 324

(1991), PP 377-384.

3THOMAS, E.J. STUDDERT, D.M., BURSTIN, H.R., ET. AL., "INCIDENCE AND TYPES OF ADVERSE

EVENTS AND NEGLIGENT CARE IN UTAH AND COLORADO," MEDICAL CARE 38 (2000), PP. 261-271.

4KOHN, L., CORRIGAN, J.M., DONALDSON, M.S., EDS, TO ERR IS HUMAN: BUILDING A SAFER

HEALTH SYSTEM. WASHINGTON, D.C.: COMMITTEE ON QUALITY ON HEALTH CARE IN AMERICA,

INSTITUTE OF MEDICINE. NATIONAL ACADEMY PRESS, 2000