Medical Errors are leading causes of death and/or injury to inpatients and account for an estimated 44,000 to 98,000 deaths in U.S. hospitals annually, according to the Institute of Medicine. The Agency for Healthcare Research and Quality (AHRQ) found that more people die from medical errors than from motor vehicle accidents, breast cancer or AIDS.
There has been increasing national emphasis on preventing medical errors. While physicians, nurses and hospital personnel are working to make health care safer, patients and their families also have a significant role. Our objective is to assist people to become active participants in their own health care. Experts consider patient involvement important in supporting safe and effective care.
A medical error, or serious adverse event, is an injury to a patient which is not due to the patient’s illness but occurs during the process of providing care. Most medical errors occur as a result of “systems" problems; medical care is complex, involving many people performing different functions.
The people who work in hospitals are professionals who are there to take care of you. Their goal is to provide treatment for your illness. However, we are all human and make mistakes. Examples of those mistakes are: giving the wrong medicine or leaving a sponge inside the body after surgery. Quite often, medical errors occur when there is a breakdown in the overall process for providing health care. Some examples of this breakdown include:
forms that are not filled out properly;
forgetting to tell someone something important;
a patient not speaking up;
Health care staff and institutions are working to make the delivery of health care safer. Many medical errors, such as surgical mistakes, can be avoided through proper procedures, such as requiring surgeons to mark and sign the surgery site while the patient is still awake. Click on Tips for Safer Surgery to find out how to reduce your risks of infection or medical error after a surgery.
The Joint Commission’s brochure, Speak Up, Help Prevent Errors in Your Care, lists important questions to ask your doctor or hospital, explains why it's important to designate a friend or loved one to act as your personal advocate, and encourages you to participate in all decisions regarding your care.
The Agency for Healthcare Research and Quality (AHRQ’s) 20 Tips to Help Prevent Medical Errors includes suggestions to prevent mistakes in medication, while in the hospital or having surgery.
Keep track of your medical history, including the prescriptions you take and your reactions to them. Keep your records manually or electronically; it may be useful to summarize your records in a chart. The FDA offers such a chart at: My Medicine Record.
If you need to go into the hospital and have the option to choose one, go to a hospital that has had a lot of experience treating your condition.
Get this information ahead of time by asking your doctor or hospital how many procedures related to your condition were performed annually over the last few years.
Ask family members or friends who have colds, other respiratory symptoms, or feel ill not to visit you in the hospital.
If you have an intravenous catheter, make sure the person inserting it wears gloves and sterilizes your skin.
keep the skin around the dressing clean and dry.
let your nurse know promptly if the dressing becomes loose or wet.
If having surgery or will be in a hospital bed for a period of time, make sure you receive the proper treatments to prevent blood clots. Visit the NJ Hospital Performance Report, Basic Facts on Surgical Care Infection Prevention, to find out about these treatments.
Hand washing is the most important task to prevent infections:
Patients often carry resistant bacteria on their skin:
Nurses, doctors and other healthcare workers can contaminate their hands by doing simple tasks, such as: taking a patient’s blood, pressure or pulse; assisting patients with mobility; touching the patient’s gown or bed sheets; and touching equipment, including bedside rails, over bed tables, and IV pumps.
Make sure that all doctors, nurses and anyone who will be touching you wash their hands before they touch you. (visit http://www.cdc.gov/cleanhands).
Ask all visitors, including family and friends, to wash their hands before entering the room.
Alcohol-based hand-rubs are recommended over soap and water, unless the hands are heavily soiled or contaminated with blood or body fluids.
Make certain you also clean your hands thoroughly at all times, while inside the hospital, at home - particularly after going to the bathroom, emptying trash and before you eat - or outside the home. Try not to touch your eyes and nose. Infections are commonly transmitted from your hands to these open areas.
Ask for assistance from the nursing staff, especially at night.
Keep your call button near you.
Keep personal items, such as medications, drinks, books and the TV remote, near you so that you do not have to get out of bed to reach them.
Report any spills or objects that are on the floor.
Wear footwear with rubber soles to prevent slipping.
Make sure that you have adequate light to see. If you wear glasses, keep them within reach.
Some medications may cause you to use the bathroom more often. Ask the nursing staff to schedule time to help accompany you to the bathroom every couple of hours.
Use all bars and handles made available to you for balance.
Be careful when using a wheelchair. Wheelchairs that have tipped over are responsible for many deaths in persons over 65 years old. Make sure the foot release, wheel locks and other parts are not loose and are working well.
If you have health insurance, make sure you have your insurance card with you.
Find out who will be your discharge planner, social worker or nurse. Make sure this person provides you with a plan for your follow-up care before you leave the hospital.
If you will need home care services, a skilled nursing facility, physical therapy or occupational therapy, get a list of referrals and set up dates for the visits ahead of time.
Try to set up dates for follow-up visits to the hospital staff (doctors, nurses, physical therapists, etc) while still in the hospital.
Ask how soon you should be feeling better after leaving the hospital.
Will you need special instructions for daily activities, e.g., taking a shower instead of a bath?
What signs and symptoms should you watch out for and what should you do if you have them?
How do you take care of any wounds you have?
How much help will you need after you leave the hospital?
Get a written list of medications that you will need and instructions. Find out about what foods and vitamins you should avoid while taking the medicine and its side effects (See Medication Safety below).
Understand what your insurance will and will not cover. If you have Medicare or Medicaid, ask your discharge planner this question.
Follow the treatment plan agreed upon by you and your doctor.
A medication error is any preventable event that may cause or lead to inappropriate medication use or harm to a patient. Since 2000, the Food and Drug Administration (FDA) has reportedly received more than 95,000 reports of medication errors.
Know the names of your medication before receiving them from the pharmacy. This way, you will know if the pharmacy makes a mistake, even when it’s a refill.
Ask questions about your medication. Some questions you should ask include:
What should I do if I forget a dose?
Should I take this medication with meals?
What time should I take the medication, morning, noon or night time?
What are the side effects?
What foods, drugs, and activities should I avoid taking with this medication?
Should the medication be refrigerated?
Know why you are taking the medication. What is the drug treating? You will be more likely to take it at the correct time if you know what it is for.
Read labels and follow directions. Read the inserts included with the medication as well as the patient medication information that the pharmacy provides along with the medication.
Never take anyone else’s prescription medication. Also, never give your medication to others.
Use only the cup or other measuring device supplied with the drug when administering liquid medications. Other measuring devices—such as household measuring spoons—may not give accurate measurements.
Choose one pharmacy to fill all your prescriptions. This way, the pharmacist gets to know you and your medicine history. The pharmacist acts as a ”checks and balance” system and can tell you if there is a potentially harmful drug interaction or if you are allergic to a certain prescribed medication.
Make sure you receive written information about the medication from your pharmacist.
Inform your doctor and other health care providers about what medications and dietary supplements you are taking. This list includes vitamins, herbs, as well as over-the-counter medications.
Tell your Doctor, Pharmacist or other Health Care Professionals all your allergies.
Who should you ask for answers to questions about medication?
Your doctor who prescribed the medication should be able to answer your questions.
Another good source is your pharmacist.
Buy all your medicines at one pharmacy. Provide your pharmacist with a list of over-the-counter medicines and dietary supplements you are taking. This way, your pharmacist can look at this list and all your prescription drugs to determine which medicines taken together can cause harmful interactions. Your pharmacist can also eliminate medication duplication.
Your pharmacist can tell you the side effects of the medicines or help you determine which medication is causing your side effects, if you are having one.
The NJ Patient Safety Reporting System (PSRS) was first created in 2004 due to NJ Patient Safety legislation requiring all NJ acute care hospitals to confidentially report medical errors to NJDOH. The reports submitted by these facilities are kept confidential to encourage facility staff to report an event that they may otherwise be embarrassed or afraid to report for fear of being penalized.
The Department works jointly with facility staff to fix the errors and set up a process that will reduce the likelihood of the error recurring. To do this, facility personal must submit a thorough analysis of the event, identify the root cause of the error and a plan to prevent the error from happening again. This analysis is called the Root Cause Analysis, or RCA. Specially trained clinicians at the Department review the analysis to make sure that it meets specific criteria. When approved, the facility puts the plan into action.
Agency for Healthcare Research and Quality (AHRQ)
This Federal agency is charged with improving the quality, safety, efficiency, and effectiveness of health care for all Americans. AHRQ supports health services research that will improve the quality of health care and promote evidence-based decision-making.
Centers for Disease Control (CDC)
The CDC's mission is to promote health and quality of life by preventing and controlling disease, injury, and disability. Find information by disease and condition, by topic, or by age.
Food & Drug Administration: (FDA)
FDA's mission is to promote and protect the public health by helping safe and effective products reach the market timely, to monitor products for continued safety after they are in use, and to help the public get the accurate, science-based information needed to improve health.
Locate information on prevention and wellness from the Healthfinder's library; get information on prescription and over-the-counter drug interaction, and link up to relevant federal and state health agencies.
The Joint Commission’ Speak Up™ Initiative:
The Speak Up Initiative is a product of a national campaign launched by the Joint Commission and the Centers for Medicare and Medicaid Services (CMS) to urge patients to take a role in preventing health care errors. The web site stresses the importance of patients becoming active, involved and informed participants on their health care team. The program features brochures, posters and buttons on a variety of patient safety topics.
MedlinePlus links to authoritative information from National Library of Medicine (NLM), the National Institutes of Health (NIH), and other government agencies and health-related organizations. It also contains information about drugs, an illustrated medical encyclopedia, interactive patient tutorials, and latest health news.
This free online service provides access to up-to-date, reliable and important research about the diagnosis and treatment of specific diseases. It provides links to the full text of selected journal articles as soon as they are published, as well as materials to help the patient or family member more fully understand the implications of the research.
Partnership for Safe Medication Use:
A group of health related organizations and individuals make up this partnership dedicated to protecting consumers from counterfeit or contraband medicines. Some of the partners include: the American Medical Association, the American Pharmaceutical Association, The American Society of Health System Pharmacists, the National Patient Safety Foundation, and Chain Drug Stores.