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The safety of the patients in our care and
treatment is an important goal during all healthcare encounters.
Early studies in the 1960s already pointed to healthcare related
errors as a problem for healthcare consumers. However, it
was the startling report in 1999, from the Institute of Medicine
(IOM) To Err is Human, that served as a wake up call
for healthcare professionals, multiple public and private
healthcare and healthcare-related organizations, state legislatures
and the federal government. The IOM report estimated that
between 44,000 and 98,000 deaths annually are a result of
medical errors; more than half of the adverse medical events
occurring each year are due to preventable medical
errors, causing the death of tens of thousands. The cost associated
with these errors in lost income, disability, and healthcare
costs is as much as $29 billion annually.
Healthcare is unique for a variety of reasons,
including the universal vulnerability of all of us when we
become patients and must rely on healthcare professionals
to provide - at a minimum - competent services. The consequences
of medical mistakes are often more severe than the consequences
of mistakes in other industries. Imagine for a moment that
the wrong tickets were provided to a patron at a concert:
inconvenient and infuriating, yes; life threatening, no. Errors
in healthcare can lead to death or disability rather than
inconvenience on the part of consumers. This high risk underscores
the need for aggressive action to resolve these errors.
Since the IOM report was issued, the issue
of patient safety has been in the forefront of the healthcare
literature, with multiple healthcare organizations putting
significant resources into safety interventions. According
to the Third Annual Patient Safety in American Hospitals
Study (p. 4, 2006):
- Approximately 1.24 million total patient safety incidents
occurred in almost 40 million hospitalizations in the Medicare
population. These incidents were associated with $9.3
billion of excess cost during 2002 through 2004. For
the second year in a row, patient safety incidents have
increased - up from 1.14 and 1.18 million reported
in the First and Second Annual Patient Safety in American
Hospitals studies, respectively.
- Of the 304,702 deaths that occurred among patients
who developed one or more patient safety incidents, 250,246
were potentially preventable.
- Medicare beneficiaries that developed one or more patient
safety incidents had a one-in-four chance of dying
during the hospitalization during 2002-2004. This rate remains
unchanged since the first study was released July 2003.
- Wide, highly significant gaps in individual patient safety
incidents and overall performance exist between the top
and the bottom performing states during 2002-2004.
- Minnesota, Wisconsin, Iowa, Michigan and Kansas ranked
as the top states for hospital patient safety during the
period studied.
- New Jersey, New York, Nevada, Tennessee and District
of Columbia, ranked last for hospital patient safety during
the period studied.
- Compared to the worst state (N.J.), the best state (Minn.)
had an overall almost 30-percent lower relative risk of
developing one or more of the 13 patient safety incidents
in its hospitals. However, performance variation between
best and worst state was even more significant with individual
patient safety incidents. For example, patients had an almost
92-percent lower relative risk of developing post-operative
physiologic and metabolic derangements (post-operative delirium)
in the top state compared to the bottom state.
- When compared to the Second Annual Patient Safety
in American Hospitals study, the rates of six key quality
improvement focus areas remained unimproved in 2004. Focus
areas include metabolic derangements, post-operative respiratory
failure, decubitus ulcer, post-operative pulmonary embolus
or deep vein thrombosis, and hospital-acquired infections.
These six areas continued to worsen on average by
almost 12 percent or more over three years (2002 through
2004).
- The patient safety incidents with the highest incidence
rates continued to be failure to rescue, decubitus ulcer,
and post-operative sepsis. Failure to rescue improved 13
percent during the study period, while postoperative sepsis
worsened by almost 25 percent.
In July, 2006 the IOM issued another report on errors in
healthcare. This report, Preventing Medication Errors,
focused specifically on the high rates of medication errors.
Most Americans have taken medication at one time or another.
It's estimated that in any given week four out of every five
U.S. adults will use prescription medicines, over-the-counter
drugs, or dietary supplements, and nearly one-third of adults
will take five or more different medications (IOM, 2006).
Some of the harm done by medications can be anticipated,
as they are the potential side effects that may be caused
by the medications. The potential benefit of using the medication
is determined by the patient and prescriber to be worth the
risk of the side effects which may be possible with the use
of a particular medication. However, some adverse drug events
(ADEs) occur as injuries that happened because of an error
in prescribing, dispensing or administering a medication.
Such errors can be prevented.
The findings of the IOM study are that medication errors
are quite common - and that they are very costly to the population.
At least 1.5 million preventable ADEs occur in the U. S. each
year. The true number may be much higher. A hospitalized
patient in the US can expect to be subjected to more than
one medication error per day!
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