Hospital Patient Safety:"Ask me if I have washed my hands."

There is no doubt that patient safety in the hospital environment is a challenge that has to be met but apparently is only doing so… slowly. The hospital is not always a safe place since a patient there may get a serious infection that he or she didn’t have on admission. They may accidentally get the wrong pill or injection medication and become very sick or die. They may be mistaken for another patient and get a procedure or test that was ordered but not for them. The limb or kidney which was normal may be removed in error while the diseased organ left in place. In the past but less likely now, within the operating room, the wrong gas had been administered by the anesthesiologists in error causing the death of the patient.

The burden of medical mistakes have been placed on the individual physician. This has led to physicians afraid to report minor mistakes that fortunately did not lead to patient injury. Since most of the medical mistakes in hospitals appear to be system errors, acknowledging and acting on these minor mistakes, if they were only reported and evaluated, might have prevented a future major medical injury. System errors in air transportation are carefully investigated and remedied, why can’t hospital errors be treated likewise?



In the Sounding Board section (page 2063) of the current May 11 2006 issue of the New England Journal of Medicine is a commentary by ethicist George Annas telling us, physicians and the hospital organizations where we practice, that based on estimates among experts in the patient safety field that little has changed to improve patient safety in hospital care since the 1999 Institute of Medicine's report "To Err is Human". The report had noted that for attempts toward improvement of patient safety "safety must be an explicit organizational goal that is demonstrated by clear organizational leadership...". Annas says this hasn't happened and he feels that the best motivating method for accomplishing attention of hospitals to patient safety, thus improving quality of care, would be through legal actions "that are focused on patient safety systems in hospitals, rather than the actions of individual physicians." He continues "Physicians cannot change a hospital's safety policy by themselves. But by working with patients (and their lawyers) to establish a patient'! s right to safety, and by proposing and supporting patient-safety initiatives, physicians can help pressure hospitals to change their operating systems to provide a safer environment for the benefit of all patients." Thus, he feels that subjecting hospital organizations who fail to investigate, change policies and then end up with errors to legal suits will improve their motivation to make hospitals safer. Further, Annas is concerned that organizations that supervise the behavior of hospital activity are also not attacking the safety problem correctly. As an example, he points to the Joint Commission for Accreditation of Health Organizations (JCAHO) recent patient-safety initiative. The JCAHO idea was to encourage physicians to wear a button that reads "Ask me if I have washed my hands." Annas states "This is an example of putting the responsibility for patient safety on the patients themselves. The fact the commission sees patient self-defense actions as an important safety strategy is a symptom of the problem, not a solution."

There are some that feel that patient safety should be an active concern for many entities including hospitals, physicians and even self-defense actions by patients themselves. What do you think? Would more law suits of hospitals help? Should patients, if possible, pay more attention and be more inquisitive and be more responsible regarding how they are being treated? Finally, do you think patients have a "right" to be safe in a hospital? ..Maurice.