Multiple approaches to safety could help prevent medical errors

There's No Substitute for Experience

Given that there is not just one cause for medical mistakes, it makes sense that there is more than one way to prevent these errors. However, the challenge is getting hospitals and staff on board with these preventative measures.

In 1999 a report titled, “To Err is Human” was released. This report, from the Institute of Medicine, found medical errors were responsible for the death of approximately 100,000 people per year. In 2009, a follow-up report found not much had changed.

Recently though, as if this 100,000 number was not alarming enough, a study found the estimate may actually be higher, with 210,000 to 440,000 people per year having the harm from a medical error contribute to their deaths.

Either way though, with thousands of people dying each year due to medical errors, it is safe to say more needs to be done to prevent these mistakes from happening.

The approach of one college was recently highlighted in an article focusing on this medical errors issue. At this college, medical students are challenged with exercises, including “root cause analysis” and using checklists.

With “root cause analysis,” students think about all of the possible factors for an illness. The idea behind this is to properly diagnose and treat a patient.

With checklists, these can be used in all types of settings, including in the operating room. These checklists could help prevent surgical errors, such as operating on the wrong patient or operating on the wrong body part.

Additionally though, Dr. Stephen Lucas, a professor of quality and safety, said sometimes the issue is not the actual medical professional, but it is the medical device.

Lucas shared one story involving a bedside pump where a doctor would type in the patient’s weight. The machine would then dispense a drug dosage based on this patient’s weight. However, in this one case, the doctor did not realize the machine was set to kilograms instead of pounds. This resulted in the patient getting the incorrect amount of the drug. Considering the fact a kilogram is more than twice the weight of a pound, the difference was significant.

In these types of scenarios, Lucas says to look at the machine. Instead of going after the doctor, he said the machine should be changed so there is no option between kilograms and pounds. Instead, make it just pounds and prevent this type of error from happening again.

Overall, in looking at prevention methods, the point here is that there is more than one type of measure that needs to be taken to prevent medical errors.

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