Nursefriendly.com: Human Errors

Showing posts with label Human Errors. Show all posts

Tuesday, August 16, 2011

amednews: Revealing their medical errors: Why three doctors went public :: Aug. 15, 2011 ... American Medical News

In September 2010, Kimberly Hiatt made a medical error. The critical care nurse at Seattle Children's Hospital miscalculated and gave a fragile 8-month-old baby 1.4 grams of calcium chloride, 10 times the correct dose of 140 milligrams.

The mistake contributed to the death of the child and led to Hiatt's firing and an investigation by the state's nursing commission. In April 2011, devastated by the loss of her job and an infant patient, Hiatt committed suicide.

Hiatt, who had worked as a nurse for more than two decades, was another in a long line of "second victims" of medical error, the term used in medical literature to describe physicians and other health professionals who often feel guilty and depressed after adverse events. Many physicians and other health professionals hold themselves to a standard of perfection, and when things go wrong, they feel alone.

via ama-assn.org

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Saturday, July 16, 2011

Medication Errors, FDA U.S. Food and Drug Administration

FDA receives medication error reports⁴ on marketed human drugs (including prescription drugs, generic drugs, and over-the-counter drugs) and nonvaccine biological products and devices. The National Coordinating Council for Medication Error Reporting and Prevention⁵ defines a medication error as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use."
The American Hospital Association⁶ lists the following as some common types of medication errors:
incomplete patient information (not knowing about patients' allergies, other medicines they are taking, previous diagnoses, and lab results, for example);
unavailable drug information (such as lack of up-to-date warnings);

via fda.gov

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Friday, July 8, 2011

When Nurse Make Mistakes (Theresa Brown, RN) - NYTimes.com

By THERESA BROWN, R.N.
This year, a Seattle nurse named Kim Hiatt committed suicide. Ms. Hiatt’s death came nearly seven months after she had given an unintended overdose to an infant heart patient, a medical error that was said to have contributed to the child’s death days later.
Ms. Hiatt had been a nurse for 27 years and had often cared for the 8-month-old girl during the child’s stay in the pediatric intensive care unit of her hospital. She had probably drawn up the right dose of the drug hundreds of times in her career. But once, she made a life-changing error. A baby died, and she was suspended, then fired from a profession she loved. And now she’s dead.

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Friday, April 22, 2011

Nurse's suicide follows tragedy | Seattle Times Newspaper

By Carol M. Ostrom

Seattle Times health reporter

Related

Crisis help
Don't wait to seek help if you're in crisis.
In King County, call: 206-461-3222 (TTY/TDD 206-461-3219).

Outside King County, call 800-273-TALK (8255).

The suicide of a nurse who accidentally gave an infant a fatal overdose last year at Seattle Children's hospital has closed an investigation but opened wounds for her friends and family members, as they struggle to comprehend a second tragedy.

Kimberly Hiatt, 50, a longtime critical-care nurse at Children's, took her own life April 3. As a result, the state's Nursing Commission last week closed its investigation of her actions in the Sept. 19 death of Kaia Zautner, a critically ill infant who died in part from complications from an overdose of calcium chloride.

After the infant's death, the hospital put Hiatt on administrative leave and soon dismissed her. In the months following, she battled to keep her nursing license in the hopes of continuing the work she loved, despite having made the deadly mistake, friends and family members said.

To satisfy state disciplinary authorities, she agreed to pay a fine and to undergo a four-year probationary period during which she would be supervised at any future nursing job when she gave medication, along with other conditions, said Sharon Crum of Issaquah, Hiatt's mother.

via seattletimes.nwsource.com

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Monday, April 18, 2011

Hung-over surgeons more error-prone | Reuters

Surgeons might want to steer clear of alcohol the night before operating, according to a new report that shows a hangover fuels errors during simulated surgery.

While there is no question about the immediate effects of alcohol on surgical skills, there aren't any rules for how much doctors can drink the day before going to the operating room.
"Historically, the medical profession has had a reputation for high rates of alcohol consumption," Anthony Gallagher, of the Royal College of Surgeons in Ireland, and colleagues write in the Archives of Surgery.
"It is likely that surgeons are unaware that next-day surgical performance may be compromised as a result of significant alcohol intake."
To measure the degree of that impairment, the researchers invited eight surgeons and 16 students out for a night on the town.

via reuters.com

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Thursday, April 14, 2011

Partnership for Patients - Win, Win, Win for American Healthcare

It's called the Partnership for Patients. (I like it already - it's focused on patients.) It's a program being developed by the federal government, under Secretary of HHS (Health and Human Services) Secretary Kathleen Sebelius, along with CMS (Center for Medicare Services) Dr. Donald Berwick, a man with an impeccable patient safety advocacy record. But they aren't in it alone - they have dozens of private and public organizations backing them, as members of the partnership.

Can this possibly be

A WIN for patients.

A WIN for providers.

And a WIN for payers, too?

via patients.about.com

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Thursday, April 7, 2011

Errors still common in U.S. hospitals | Reuters

About one in three people in the United States will encounter some kind of mistake during a hospital stay, U.S. researchers said Thursday.

The finding, which is based on a new tool for measuring hospital errors, is about 10 times higher than estimates using older methods, suggesting much work remains in efforts to improve health quality.
"Without doubt, we've seen improvements in health care over the past decade, and even pockets of excellence, but overall progress has been agonizingly slow," said Susan Dentzer, editor-in-chief of Health Affairs, which published several studies on a special issue on patient safety.
The special issue came 10 years after an influential Institute of Medicine report that found significant gaps in health quality.

via reuters.com

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Wednesday, March 30, 2011

How safe is your hospital? - chicagotribune.com

Just before it was disclosed that a medical error at the University of Chicago led to the death of James Tyree, a well-known financier and philanthropist being treated for cancer, I was putting together a presentation examining the quality of care at some of the area's best-known hospitals.
Using publicly available data, I told a meeting of local health care executives that there were warning flags at several institutions, including the U. of C. Tyree, ironically, would have known about any actual problems in far greater detail. He served on the board of the hospital where he died from an air embolism in a dialysis catheter, and hospital officials said in an interview that they regularly report safety data to board members.
There's an important distinction between great doctoring and great safety. The U. of C. has a reputation for outstanding cancer care. That's likely the reason that Tyree, suffering from stomach cancer and pneumonia, had a relatively good prognosis when he entered the hospital and why his death so shocked his family and friends. But as a wise physician once warned, "Every hospital should have a plaque at its entrance that reads, 'There are some patients whom we cannot help; there are none whom we cannot harm.'"

via chicagotribune.com

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AIM: Adverse event reporting is on the rise

Although the FDA's Adverse Event Reporting System (AERS) database has been in existence since 1969, more than half of the incidents in it were received in the past decade, according to an article published online March 28 in the Archives of Internal Medicine.
These 2.2 million events represent a 1.65-fold increase from the prior decade, wrote Sheila Weiss-Smith, PhD, from the University of Maryland School of Pharmacy in Baltimore, and colleagues. "Report volume increased from 2000 to 2010 at a mean annual rate of 11.3 percent,” the authors continued.
AERS is a repository of passively reported adverse drug events designed as a safety net so the FDA can monitor all marketed drugs and detect serious safety problems. Weiss-Smith and colleagues sought to characterize the current reporting patterns.

via cmio.net

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The Epidemic of Preventable Medical Harm, HealthcarePSI.org

The Centers for Disease Control reports that 1.7 million people who enter the hospital this year - for any reason - will contract a Hospital Acquired Infection which is completely unrelated to the condition they entered with, and 99,000 of those patients infected will die within the year. Many thousands more will never fully recover.
The Sepsis Alliance - a physician group studying the condition - states that 215,000 people die each year from sepsis, a blood stream infection. The Alliance also states that half of those deaths could be prevented if hospitals would identify and treat patients in a timely manner.
In November 2010, the Office of the Inspector General released a damning report stating that every month in US hospitals, 15,000 Medicare patients over the age of 65 are killed by preventable medical harm. That's 180,000 needless deaths a year. Another 45,000 Seniors on Medicare are injured every month, but survive their hospitalization.
The three studies above document more than 386,000 preventable deaths a year in US hospitals - and that's only a small glimpse of a problem that has reached epidemic proportions.
The Institutes of Medicine estimates there are 100,000 documented preventable harm deaths per year, however they also reluctantly admit that only 5%-20% of preventable medical harm incidents are ever documented on patient records. That means their figure is badly underestimated. By how much? You do the math.

via healthcarepsi.org

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Sunday, March 27, 2011

Admitting harm protects patients - Sunday, March 27, 2011 | 2 a.m. - Las Vegas Sun

As Nevada legislators debate this week whether to require hospitals to publicly report when they harm patients, they could learn a lot from Paul Levy’s experience in pulling back the veil of hospital secrecy.

Levy became a revolutionary figure in medicine when, as CEO of Beth Israel Deaconess — then the weak sibling among Harvard University’s teaching hospitals — he began blogging about injuries and infections suffered by his hospital’s patients. His competitors eventually followed suit and now, with Massachusetts law imposing transparency, they acknowledge openness has brought greater accountability and a more focused commitment to protecting patients.

“It’s not just fear of public embarrassment” that drives the improvements, said Dr. Ken Sands, chairman of Beth Israel Deaconess Medical Center’s health care quality department. “It’s an easy way to show something is a priority and is deserving of attention.”

via lasvegassun.com

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Saturday, March 26, 2011

Normal sleep a 'privilege' for night workers - CNN.com

Gregory Jones begins his day when his family and the rest of the world winds down and gets ready for bed.

The New Jersey truck driver reports to work at 8 p.m. He loads, stacks and transports vegetables and fruits until 4 a.m.

"I don't get eight hours," Jones said about his workday sleeping habits. "Sleep for me is a privilege. It's a blessing if I can get it."

Night workers like Jones are at higher risk for heart disease, diabetes, and other conditions. With biology beckoning their bodies to sleep during the night, shift workers say they struggle to stay awake no matter how many years they've done it.

When sleep prevails, there can be major consequences for others as well.

On Wednesday, two airplanes landed at Ronald Reagan Washington National Airport shortly after midnight without an air traffic controller.

via cnn.com

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Tuesday, August 16, 2011

amednews: Revealing their medical errors: Why three doctors went public :: Aug. 15, 2011 ... American Medical News

Saturday, July 16, 2011

Medication Errors, FDA U.S. Food and Drug Administration

Friday, July 8, 2011

When Nurse Make Mistakes (Theresa Brown, RN) - NYTimes.com

Friday, April 22, 2011

Nurse's suicide follows tragedy | Seattle Times Newspaper

Monday, April 18, 2011

Hung-over surgeons more error-prone | Reuters

Thursday, April 14, 2011

Partnership for Patients - Win, Win, Win for American Healthcare

Thursday, April 7, 2011

Errors still common in U.S. hospitals | Reuters

Wednesday, March 30, 2011

How safe is your hospital? - chicagotribune.com

AIM: Adverse event reporting is on the rise

The Epidemic of Preventable Medical Harm, HealthcarePSI.org

Sunday, March 27, 2011

Admitting harm protects patients - Sunday, March 27, 2011 | 2 a.m. - Las Vegas Sun

Saturday, March 26, 2011

Normal sleep a 'privilege' for night workers - CNN.com

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