Hospital errors not budging

Despite continued efforts to improve, hospitals in Minnesota are still committing preventable mistakes, reported the Star Tribune. Of the 314 reportable errors in a 12-month period, 14 involved patient deaths and 89 resulted in severe injuries.

Although rare, the same severe errors are occurring even with time-outs in the operating room. Errors can occur once every 10,000 procedures, the newspaper noted.

"The fact that you did the time-out doesn't tell us the quality of how that was done," Lawrence Massa of the Minnesota Hospital Association said.

Errors may occur because of holes in the system.

For instance, at Phillips Eye Institute in Minneapolis, surgeons used to bring all of their lenses for the day into an operating room and stack them in order. But if one patient canceled, the order of lenses would remain the same, which resulted in patients receiving the incorrect implant.

Patients are particularly vulnerable to errors during shift changes, according to Mike Smith, a personal injury attorney in Arkansas. Known as the "portfolio effect" phenomenon, the early cases on the list get more attention than the last cases. When providers are rushing, the patients at the end may be shortchanged.

Smith encourages providers to use a shift-change model from Massachusetts General Hospital, in which sicker patients get the most attention. Shift change and charting begins with the most acute patients and works down to less severe cases.

The Institute for Safe Medication Practices (ISMP), in Horsham, Pa., encourages interdisciplinary education to prevent errors, specifically for drug safety.

According to the Institute, nearly three quarters (72 percent) of hospitals don't have nurses spending time in the pharmacy during orientation, and nearly half (47 percent) don't include pharmacists on medical staff orientation, Pharmacy Practice News reported. And about a third (34 percent) of hospitals don't assign new staff pharmacists to patient-care unit training.

James A. Haley Veterans Hospital and Clinics in Tampa, Fla., however, stresses teamwork and builds error prevention in daily routine with morning reports on safety. In addition, the hospital holds weekly 15 minute sessions on patient safety or quality issues.

"It's often entertaining and very interactive, so no one gets too bored, and they learn a little bit along the way," said Alexander Reiss, chief of the hospitalist section.

For more information:
- here's the Star Tribune article
- read Mike Smith's brief
- see the Pharmacy Practice News article

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