From Our 2011 Archives
Hospital Errors May Be More Common Than Thought
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New Tracking Tool Suggests Medical Errors May Occur in One-Third of Hospital Admissions
By Denise Mann
Reviewed by Laura J. Martin, MD
April 7, 2011 -- Medication errors, infections, and other hospital-related errors may be 10 times more common than previously estimated, according to a study involving a new tracking tool.
Medical errors may actually occur in as many of one-third of hospital admissions, according to a new study in the April issue of Health Affairs.
"It's a little scary," admits study author David C. Classen, MD, an associate professor of medicine at the University of Utah in Salt Lake City.
Whether the problem is getting worse or error tracking methods are improving is not known. "We have gotten better tools to detect medical errors which give us a better yardstick to determine if we are improving," he says.
Researchers used the Institute for Healthcare Improvements' Global Trigger Tool. With this method, two or three trained nurses or pharmacists review medical charts for certain triggers such as a stop-medication order, an abnormal lab test result, or the use of a known antidote, and then follow up with a physician review of the medical chart to see if these triggers led to any medical mistakes.
Study results show the new tool may be more sensitive than other tracking methods, including voluntary reporting and other measures.
Protect Yourself From Hospital Errors
Common hospital errors included medication-related issues, procedure-related mistakes, and hospital-acquired infections. The most severe mistakes were related to a surgery or procedure, the new study showed.
Classen says that asking questions and demanding answers can help reduce the risk of medical errors when you are hospitalized.
If someone tries to give you medication, "stop and say 'I want to hear all about it before I take it,'" he suggests.
Before surgery, "insist that your surgeon comes and sees you before starting the procedure to review the steps," Classen says.
A patient advocate is important, he says. "If you don't have family, you need another advocate to watch over things."
"If your surgery involves the use of any type of device such as a urinary catheter, ask daily when it is coming out," he says. These devices can increase your risk of developing an infection and should be removed as soon as they are no longer medically necessary.
Patient safety expert Peter Pronovost, MD, professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine in Baltimore, says that the new tracking tool is far from fail-safe.
For example, "it is considered a bad outcome if I gave you Benadryl because you are itchy and most pain medications cause you to itch," he says. There was also no standardized definition for infections used with the new tracking tool.
"Not to say that safety is not a problem, but this tool is not a good measure of the problem," he says
There are some ways to protect yourself and your loved ones when in the hospital, Pronovost says. "Ask about the hospital's bloodstream infection rate. It should be 1% or lower."
Also ask (and observe) whether staff members wash their hands when they enter your room, he says.
"Practice makes perfect," he says. "If your doctor doesn't do a lot of the surgery you need, then go to another place if possible."
Also paying close attention to your discharge instructions can also make a difference in your risk of complications. Know what to look out for and what medications you can or can't take and how to take them, he says.
"I wouldn't say this new data is scary for patients but it is another call to action to raise awareness about this issue," says Diane C. Pinakiewicz, president of the National Patient Safety Foundation in Boston.
"The findings are sobering, but equally sobering was the path that we were on before we had tools like this," she says. "Now that we really understand the problem, we can focus on improvement efforts."
SOURCES: Classen, D.C. Health Affairs, 2011.David C. Classen, MD, associate professor of medicine, University of Utah, Salt Lake City.Diane C. Pinakiewicz, MBA, President, National Patient Safety Foundation, Boston.Peter Pronovost, MD, professor, anesthesiology and critical care medicine, Johns Hopkins University School of Medicine, Baltimore.