Medical Mistakes, 10 Years Post-Op

The Hospitalist. 2009 November;2009(11):

November 1, 2009 | The Hospitalist

“The patients who enter hospitals today are incredibly sick, with multiple organ failures and other complications. Taking care of these patients is incredibly challenging, and there are always going to be things that do not go well. Hospitalists have begun to uncover and tackle a lot of these problems, but even as they eliminate one problem, new treatments, devices, procedures and strategies for caring for patients—all designed to improve care—may have unintended consequences. It is hospitalists’ job to try to mitigate those consequences and redesign the strategies to continue to improve outcomes. But this is a long road—a marathon, not a sprint.”—Scott Flanders, MD, FHM, director of the hospitalist division, University of Michigan Health System, Ann Arbor; president of SHM

“The greatest area of unfinished business I see is preserving continuity of care for our patients as they transition in and out of the hospital. So much is happening, and there is a great need to get information quickly and communicate between the inpatient and community-based practitioner. I should say we’ve come a long way, but there’s a lot more to do in this area, and that’s why six medical societies, including SHM, came together to produce the recent Transitions of Care Consensus Statement, acknowledging that this is a crucial part of patient safety and describing what are effective transitions of care in and out of the hospital.”—Vineet Arora, MD, MA, FHM, assistant professor, Department of Medicine, University of Chicago

—LB

Campaign to Rid Hospitals of Errors

By Larry Beresford

The Cambridge, Mass.-based Institute for Healthcare Improvement and its partners developed the 100,000 Lives Campaign in 2005 to encourage hospitals and healthcare providers to eliminate preventable medical mistakes. The campaign goal expanded to 5 million lives in 2006, but still recommends the following steps:

Deploy Rapid Response Teams (RRTs) … at the first sign of patient decline;
Deliver reliable, evidence-based care for acute myocardial infarction … to prevent deaths from heart attack;
Prevent adverse drug events (ADEs) … by implementing medication reconciliation protocols;
Prevent central-line infections … by implementing a series of interdependent, scientifically grounded steps called the “Central Line Bundle”;
Prevent surgical-site infections … by reliably delivering the correct perioperative antibiotics at the proper time; and
Prevent ventilator-associated pneumonia … by implementing a series of interdependent, scientifically grounded steps including the “Ventilator Bundle.”

When reliably implemented, these interventions greatly reduce morbidity and mortality. For more information, visit www.ihi.org/IHI/Programs/Campaign.