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Since the 1999 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 national study, 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. 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. In 2008 the actor
Dennis Quaid and his wife became celebrity spokespersons regarding
medication errors after their twin infants, in November, 2007,
were given 1,000 times the dosage of heparin than was ordered-twice!
In that situation, according to their 60 Minutes interview
(March 16, 2008), the error occurred because a pharmacy technician
stored the higher heparin doses in the wrong place and a nurse
who administered the drug to the babies failed to verify the
amount. Additionally, the Quaids then also sued Baxter Healthcare
Corp., accusing the company of negligence in packaging different
doses of Heparin in similar vials with blue backgrounds.
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!
In the state of Florida, medical errors have improved, as
per the above Third Annual Patient Safety in American Hospitals
Study. Florida was among the16 states that performed statistically
significantly better than expected. Florida health officials
have been collecting data on medical mistakes from hospitals
and walk-in surgery centers since 2001. The reports do not
include hospital names; they identify aggregate data only.
Despite the improvement noted above, data collected by Florida
officials indicate that more than 1,000 patients died in Florida
hospitals from adverse events between January 2001 and June
2004. Additionally, nearly 400 patients have needed surgery
to remove a sponge or other object left inside them in a prior
operation (Gaul, Washington Post, 2005).
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