What you should know about Preventable Harm
What Is Preventable Harm?
The lack of a clear definition agreed obfu¬scates a full understanding of the nature of avoidable harm. Most working definitions include the idea that the injury is "identifiable" in that it can be attributed to medical care and "modifiable" in that it can be avoided. For the purposes of this article, we will use the Institute for Healthcare Improvement definition preventable medical injury as "Unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment) that requires monitoring additional, treatment or hospitalization, or results in death. "Definition of preventable harm is important because some studies suggest that up to half of the experience of risk patients in hospitals are not preventable or not the result of an identifiable error. In addition, there is evidence contradictory regarding the prevalence of avoidable harm.
the elimination of avoidable harm is certainly a desirable goal, but in practice, it can not really be possible. the sad fact is, while damage may be "avoidable", a certain level of harm is considered inevitable because of health professionals, like everyone else, make mistakes. nosocomial infections, misdiagnosis, poor surgeries, medication errors, falls and burns in hospital, some cases of deep vein thrombosis, infections and surgical site bedsores are common examples.
the most common Preventable Harm
surgery| TYPE OF HARM | EXPLANATION | PREVALENCE / INCIDENCE |
|---|---|---|
| nosocomial infections | nosocomial infections are caused by bacteria, viruses or fungal agents. Common types include infections of the blood stream, pneumonia, surgical infections, urinary tract infections and methicillin-resistant Staphylococcus aureus (MRSA). | A Centers for Disease Control and Prevention Survey found that on any given day, an estimated 25 January hospitalized patients are affected by a nosocomial infection |
| error surgical -. Wrong Site Surgery | Wrong Site Surgery include running on the wrong side or on the site of the body, performing the surgical procedure and poorly performing surgery on the wrong patient. | agency for Healthcare Research and Quality Study that analyzed the information of nearly 3 million operations between 1985 and 04 found a rate of 1 to 112,994 surgical cases wrong-site. |
| medication errors | medication errors include prescribing errors, dispensing errors, administrative errors and medication errors compliance of patients. | Somewhere between 3 and 6 percent of patients experience medication errors each year. |
| In-Hospital Injury | most injuries in the hospital are the result of falls. | rate falls in US hospitals range from 3.3 to 11.5 falls per 1,000 patient days. |
| Misdiagnosis | There are three types of medical misdiagnosis
| No reliable information on diagnostic errors. The available studies vary widely in their conclusions. |
| Deep vein thrombosis (DVT) | DVT is a blood clot that forms deep in the body, usually in the bottom of the leg or thigh. When a blood clot breaks off, it can travel through the bloodstream and block blood flow in the lungs, heart or brain, causing an embolism. DVT risk is greater when the hospital because surgery and major immobility can both cause deep vein thrombosis. | A Centers for Disease Control and Prevention Study found the annual hospitalization rate estimated for DVT to 547,596 from 07 to 09. It is not known how many of these cases could have been avoided. |
What are the costs?
The avoidable harm to human toll is staggering. The most cited statistics come from a famous 1999 report by the Institute of Medicine (IOM) "To err is human." The report, one of the first one to put the hard science to the study of avoidable harm, shocked readers by letting 98,000 people die each year due to preventable adverse events. While many still cite that figure today, more recent studies of the same rigor estimate the true prevalence of avoidable damage to be much higher -. Between 210,000 and 440,000 cases per year
In addition to avoidable toll of injury takes human life, ample evidence suggests medical errors cost health consumers billions of dollars each year. A 2012 study broke down those costs in additional medical bills ($ 17 billion), the mortality rate increased ($ 1.4 billion) and lost productivity ($ 1.1 billion). Including the indirect costs of preventable harm, the economic impact could easily reach $ 1000000000000 annually. It should be noted that these cost analyzes are based on the number of incidents provided by IOM "To Err Is Human" study - if the calculations were redone with the highest figures reported by more recent studies the resulting cost would be 10 times higher.
Preventable injury fee also an emotional impact on everyone involved. Treat cases of avoidable harm means doctors have patients in their care for a longer period of time, nurses have more patients, and resources are stretched - creating an environment that could produce more cases of damage and loss morale. Family, friends and caregivers are affected as they put more time and effort to help the family recover. Finally, patients take more time off from work, school and other activities they like to regain full health.
What can we do to avoid this?
To prevent damage, government, governing bodies and professional organizations are doing their best to develop guidelines and best practices based on evidence to raise the level of care. When things go wrong it is usually multifactorial and involves a systematic or human error (and sometimes both). systematic guarantees are generally in place to prevent human error. So systematic failures as dysfunctional teams, lack of resources, poor communication, administration of poor health, ignore safeguards and checklists, or the predicate often malfunctioning technology and facilitate human error such as lack of knowledge or skills, fatigue goalkeeper and technical errors. Continuous monitoring of adverse events, as well as work to update policies and protection measures, is the best defense against the repeated adverse medical events.
As we develop new treatments and guarantees, which seems inevitable today may be tomorrow preventable. How to care standards are developed and put into practice? Let's look at a common example: An elderly patient falls out of her hospital bed to go to the bathroom. The patient requires care more driven to put his arm and prevent infection, and it does not leave the hospital until several days past its original release date. After getting home, friends and family should watch her and help with daily tasks.
Back at the hospital, a team of health care providers and administrators to investigate whether intervention on their part would have prevented the patient from falling. nursing staff was spread too thin to meet its final deadline? If it has been equipped with a catheter or bedpan? The ground was wet? She was given anti-slip socks? There are three possible outcomes to such investigation: (1) they might find that the current standards of care would not have prevented the fall and amend them accordingly; (2) they might find that there are reasonable safeguards in place, but they are not followed; (3) they could find there was no way to prevent the problem in the first place.
The analysis of the hospital believes that although all current guarantees were respected, no one discusses the high risk for falls with the patient, and the patient is not considered at high risk for a fall. To avoid this happening in the future, additional security has been set up where the nurse communicates service with the patient about the danger of falling from the hospital and encouraged not to leave his bed without assistance .
There are many resources available for those looking to reduce the number of adverse medical events. Many non-profit organizations, healthcare organizations and government agencies are working to provide both the public and the medical community with the latest and greatest in health care innovations. In addition, it is important that we educate the next generation of doctors, nurses and health administrators to understand the severity of preventable adverse medical events and encourage innovation in the search for solutions.
Additional Resources
National Patient Safety Foundation
a 501 (c) (3) nonprofit, the National Patient Safety Foundation (NPSF) has been a central voice for patient safety since 1997. NPSF organizes awareness week patient safety and provides resources for patients, families and professionals in health care.
Synensis
Synesis is a consulting company in Georgia, which works with hospitals to help them pursue "zero preventable injury." Their customers include the Mayo Clinic, Inova Health Department of Veterans Affairs of the United States and the system.
Movement of patient safety
Founded by Joe Kiani, the Movement of the patient safety called hospitals, physicians and medical device manufacturers to make commitments to reduce damage preventable. Massachusetts General Hospital, Baylor Scott and White health care system, and GE Healthcare are among the health care organizations that aspire to achieve zero deaths from preventable harm by 2020.
National Forum quality
the National quality Forum (NQF) is a "body without nonpartisan profit, membership-based catalyst that works to improve health care." in 2012, approved the NQF implementation of security measures 26 patients related to medical errors.
patient safety America
Dr. John T. James, the former chief toxicologist of the National Aeronautics & Space administration (NASA), established Patient Safety America. He started the organization after her son died in 02 after what he described "the care uninformed, careless and unethical by cardiologists in a hospital in central Texas. "a national patient hospitalized bill of rights is among the objectives of the organization's policy.
Beth Israel Deaconess Medical Center
Beth Israel Deaconess Medical Center is a hospital model of transparency. Its website provides statistics preventable harm updated by injury type and detailed accounts of how he works to address these issues.
Hospital Safety Score
Founded by the Leapfrog Group, security Score hospital assigns safety scores to nearly 2,500 hospitals across the country. The scores allow patients and families to understand how reliable a particular hospital provides care away from the correct use of antibiotics to the frequency of employee handwashing.
Partnerships for patients
Led by the Center for Medicare and Medicaid Services, partnerships for patients is a collaborative effort between health providers and the federal and state to make hospitals safer.
Gordon and Betty Moore Foundation
With its patient care program, the Gordon and Betty Moore Foundation has spent $ 49 million in 2013 on projects that "eliminate avoidable harm and costs of unnecessary health care. "Beth Israel Deaconess Medical Center, Brigham and Women's Hospital and the University of California, San Francisco, were among the beneficiaries of subsidies.
IHI global Trigger tool
the global Trigger tool allows researchers to comb triggers or clues to "measure the overall level of damage within a healthcare organization."
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