A Case-Based Comprehensive Guide Abha Agrawal Editor
Total Page：16
File Type：pdf, Size：1020Kb
Abha Agrawal Editor Patient Safety A Case-Based Comprehensive Guide 123 Patient Safety Abha Agrawal Editor Patient Safety A Case-Based Comprehensive Guide Editor Abha Agrawal, M.D., F.A.C.P. Norwegian American Hospital and Northwestern University Feinberg School of Medicine Chicago , IL , USA ISBN 978-1-4614-7418-0 ISBN 978-1-4614-7419-7 (eBook) DOI 10.1007/978-1-4614-7419-7 Springer New York Heidelberg Dordrecht London Library of Congress Control Number: 2013941354 © Springer Science+Business Media New York 2014 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifi cally for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher’s location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) To patients: they teach us everything. To Mummy and Papa: who made it possible to learn. Pref ace The fundamental premise of this book is the following: patient safety has always been at the core of medical professionals’ ethic and value since Hippocrates and Florence Nightingale implored us to “do no harm.” The newness in the patient safety movement of the last decade lies in a better understanding of the prevalence, causes, and potential solutions for medical errors. Why is learning about patient safety critical to all healthcare professionals? We don’t go to work to perform an operation or to administer medications; we go to work to treat, cure, and heal sick people. So of what value is the superb technical skill of a surgeon to a patient whose healthy leg gets amputated due to a trivial mistake in patient identifi cation by a team of surgeons and nurses in a hurry? What good is the advanced skill and training of a specialized physician if a patient dies after receiving 100 times the dose of an anticoagulant caused by a trivial error in labeling the bag of intravenous medication? How do you console the mother of a newborn baby who dies due to an unwarranted and inexplicable delay in performing a Cesarean section caused by a breakdown in teamwork and communication between the obstetrician and the nurse? Death is binary; your patient is either alive or dead. And once some- one is dead there is no coming back. Therefore, if delivering good outcomes for patients is at the heart of our profession, we have as much professional obligation to learn about the adverse events—the diseases of healthcare delivery system, as we have to learn about biological diseases—diseases of human body system. The purpose of this book is to engage front-line clinicians and move patient safety from the boardroom to the bedside because only by practicing patient safety, will we be able to make a difference in the lives of our patients and their families. Error in Medicine The evidence is now incontrovertible that many patients suffer serious harm due to avoidable adverse events in health care such as medication errors, hospital- acquired infections, surgical complications, and delays in necessary treatments. vii viii Preface These adverse events happen in every setting—clinic, hospital, emergency room, rural, urban, community center, academic hospital—across the globe to patients of all age groups, ethnicities, and socioeconomic backgrounds. They could happen to your patients and mine. And this is not new. In 1964, Schimmel reported that 20 % of patients admitted to a university hospital suffered iatrogenic injury and that 20 % of those injuries were serious or fatal [1]. A 1981 report found that 36 % of patients admitted to the medical service in a teaching hospital suffered an iatrogenic event, of which 25 % were serious or life threatening [2]. In 1991, Leape et al. reported the results of a population-based study conducted in New York and found that 3.7 % of patients had “disabling” injuries as a result of medical treatment and that “negligent care” was responsible for 28 % of them [3]. Another 1991 study found that 64 % of cardiac arrests at a teaching hospital were preventable [4]. In spite of a multitude of reports, much of the discussion of error in medicine remained confi ned to the academic journals until the landmark 1999 report, “To Err is Human” catapulted the issue of preventable patient harm from academia into public discourse. The report estimated 48,000–98,000 deaths per year in US hospi- tals from medical errors and shocked the world by equating these deaths with the graphic analogy of one jumbo jet crashing per day [5]. More recently, a 2010 analysis of Medicare benefi ciaries found that at least 13.5 % of hospitalized patients suffer an adverse event and almost half of these are preventable. The report concluded that about 15,000 patients (from the Medicare population alone) die in US hospitals every month as a result of potentially prevent- able adverse events [6]. These fi ndings led healthcare experts to conclude that health care in the USA has an appalling problem of “waste, danger, and death”—words used to describe the grave condition of America’s highway systems by President Eisenhower in a 1954 speech.1 Although the aforementioned reports are from the USA, a similar concern about adverse events has been found in hospitals around the world. Two widely quoted studies based on retrospective review from British hospitals found that approxi- mately 10 % of patients experience adverse events; a third to half of these are pre- ventable and often lead to disability and death [7, 8]. Similar fi ndings have been reported from hospitals in Canada [9], Sweden [10], Brazil [11], Australia [12], and the Netherlands [13]. In a report from Israel, clinicians in a medical–surgical inten- sive care unit of a university hospital made 554 errors over 4 months or 1.7 errors per patient per day [14]. A recent 2012 report evaluating the extent of adverse events in developing countries (Egypt, Jordan, Kenya, Morocco, Tunisia, Sudan, South Africa, and Yemen) found that 8.2 % of the medical records showed at least one adverse event. Of these events, 83 % were judged to be preventable, and about 30 % were associated with death of the patient [15]. The report concluded that “unsafe 1 President Dwight D. Eisenhower 1954 speech available at http://www.fhwa.dot.gov/interstate/ audiogallery.htm . Last accessed Dec 30 2012. Preface ix patient care represents a serious and considerable danger to patients in the hospitals that were studied, and hence should be a high priority public health problem.” This irrefutable evidence of error and harm has spurred the healthcare commu- nity to action and there is now a global conversation about patient safety. Over the last decade, patient safety has become a focus of attention of healthcare leaders, quality experts, journalists, and concerned citizens. The Federal Government of the USA passed the Patient Safety and Quality Improvement Act of 2005 to create a network of patient safety organizations and to promote a culture of safety in health care. The World Health Organization created the World Alliance for Patient Safety to foster global awareness. The 2009 American Recovery and Reinvestment Bill (ARRA) provides for approximately $36 billion in incentive payments to hospitals and offi ce practices who demonstrate “meaningful use” of electronic health records; improvement of quality and safety is a core component of the “meaningful use” criteria defi ned by the federal law. Patient safety is moving to the forefront of the strategic priorities agenda of most hospitals, regulatory agencies, improvement organizations, as well as legislative bodies. The Institute of Medicine defi nes patient safety simply as “freedom from acciden- tal injury [5].” Moreover, patient safety is also now an emerging scientifi c discipline— a fi eld of both inquiry and action. Experts have defi ned it as “ a discipline in the health care sector that applies safety science methods toward the goal of achieving a trust- worthy system of health care delivery. Patient safety is also an attribute of health care systems that minimizes the incidence and impact of, and maximizes recovery from, adverse events [16] . ” Implicit in this defi nition is the understanding that with con- certed systematic efforts, much of the harm from medical errors can be prevented. Why This Book? Despite a fl urry of activities in patient safety, many of my fellow practicing clini- cians on the front line—physicians, nurses, ancillary professionals—remain disen- gaged if not disenfranchised from this important conversation.