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

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Monday, May 15, 2006

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.

2 Comments:

At Monday, May 15, 2006 8:46:00 PM, Anonymous Moof said...

I think that patient safety involves a concerted effort on everyone's part ... hospital personnel who deal with records, nurses, technicians, doctors, patients - and the people who clean the rooms, and deliver the food trays!

If the patients have guests, then they're also involved ...

"Finally, do you think patients have a "right" to be safe in a hospital?"

That's a loaded question. "Rights" are funny things. Each person has the right to be treated properly, and safely. But there's a natural "right" that supercedes that, and it's the "right to be a human being" ... which means that there will be mistakes. Humans are not infallible - even when they're doctors. Nurses are also not infallible ... and patients often have no idea what constitues "safety" in a hospital.

As far as more lawsuits! No! Patient education, yes. Not having hospital personnel who are asleep on their feet from pulling heavy duty and long hours would also help.

But ... all of that being said, you still have to come back to the fact that people are people, and no matter how careful they are, or how hard they try, mistakes are still going to happen.

 
At Wednesday, May 17, 2006 10:16:00 AM, Blogger Alyssa said...

Last year, I saw a very interesting presentation by Dr. Robert Watcher on medical mistakes. He published a book titled, Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes.

One of the main points of his presentation was that, yes, individuals make mistakes, but often, the most egregious cases are not due to the errors of one person, but rather of a host of people in the system. It is the idea that when all the holes in the system ultimately line up, major errors are made.

I think that a large reason for medical mistakes is assumption and hierarchy. I have certainly been in situations where there have been bright red flags waived in my face, but I minimized their importance because a) I assumed I must be wrong if a trusted colleague appears to be faltering/missing something critical, or b) because the mistake is being made by a superior and I assume that he/she is correct and/or fear that I will personally suffer if I mention the issue.

Doctors are known for being arrogant, in control, top of the food chain, etc. When I have challenged my physicians on diagnosis and treatment options, they have often been caught off guard and somewhat offended. I think that many patients keep fears and observations hidden. I believe that patients should feel compelled (and hopefully comfortable) bringing up issues of their care - inquisitiveness and attention will help rather than hurt in most cases.

I agree with Moof that the question regarding the "right to safety" is loaded, but I still feel very strongly that patients should be able to assume that they will be treated in the safest possible way when receiving medical care. I think that patients have a right to receive adequate care from the medical community and an integral component of that care is that it is provided safely and correctly. There is NO EXCUSE for many of the mistakes that are made in hospitals all over the country: amputating a healthy limb instead of the gangrenous one, administering the incorrect dose of medication or the wrong medication all together, etc., etc., etc. Inexcusable.

Medicine is in need of a culture shift. No one is looking forward to it, but it needs to happen. We cannot put the blame on one person when it is so often a series of mistakes that caused an error. We can no longer rely on the idea that "Oh well, people make mistakes. It won't happen again," allowing us to sweep the issue under the rug, time and time again. We must identify weaknesses in the system and systematically fix them. It will require innovation and hard work, but the outcome of greater patient safety will be worth the cost.

 

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