Each patient who seeks help in a medical institution is experiencing some ambivalent feelings. On the one hand, it is a feeling of deep faith in power of modern medicine, in high level of responsibility and expertise of the attending personnel. On the other hand a patient is inspired by personal experience, experience of uncertainty that as a result of medical care come complete freedom from illness and recovery. The patient is not insured from the mistakes of the physicians. There is no accurate data on how many of these cases exist because not every victim seeks justice. This paper examines two types of sentinel events - wrong-site surgery and medication errors, as well as possible ways to prevent them.
In the last decades, a number of surgical errors has been growing steadily. Messages about "surgery at a wrong place," began to appear much more often. According to the organization that is supervising the operations of US hospitals, there is an increase in the number of surgical errors in which a surgeon operates on the wrong body part or wrong patient. In 1998, there were only 61 such incidents, but last year there are 58 cases. These errors include surgery on a wrong finger, replacement of the wrong hip joint, melting of a wrong vertebral disc, cataract extraction in the wrong eye and brain biopsy on the wrong side. The cause of such misunderstandings is considered to be the human factor.
Orthopedic surgery includes surgery on the extremities when it is possible to confuse the right and left sides. It is the area where the largest number of errors occurs and reaches 40% of cases. About 20% are general surgery, which pertains mainly to the abdominal cavity, 14% from neurosurgery, 11% - for urology, and the rest - in the thoracic, cardiovascular surgery, ENT, ophthalmology and maxillofacial surgery. 58% of the errors occurred in outpatient or counseling medical centers; in 29% of cases - in operating hospitals and 13% of cases - in emergency rooms and intensive care.
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In 2008, in Methodist Hospital, Minnesota, United States, a healthy kidney was mistakenly removed from a cancer patient. In the patients medical record, there was incorrect data on the side of the cancerous organ. The surgeon who conducted the operation has voluntarily suspended himself from work. Hospital unconditionally fully recognized its responsibility for making a tragic medical error. Methodist Hospital earlier was not noted for such serious errors related to the surgery from the wrong side of the body. However, in 2006, there have been two cases associated with carrying out the diagnosis of diseases of the lungs and bronchi on the wrong side.
According to data the study by Bingener, at the Mayo Clinic, the staff has conducted about 1.5 million invasive procedures in course of 5 years. In 69 cases, doctors have made serious mistakes. The most common violation was conducting an incorrect surgical operation. At the Mayo Clinic, it happened 24 times. The unnecessary surgery on the wrong side of the body or in the wrong area was performed 22 times. Thus, one blunder accounted for 22 thousand of transactions made correctly. About two-thirds of violations have occurred during conducting relatively simple procedures. In the Bingeners study, author stressed that none of the error was the cause of death of the patient.
In1995, the surgeon amputated the healthy leg. Thus, the patient lost both his legs. The surgeon noted the wrong leg for all procedures in his writings and believed that he was working on "true" leg. The surgeon was denied a license. Wrong-site surgery is a very dangerous mistake which in extreme cases such as surgery on the brain can lead to death.
Only a small number of wrong-site surgery errors led to death. However, some of them have led to very serious consequences, for example, removal of a healthy kidney instead of the one in which has malignant tumor. However, the majority of these cases led to a permanent disability in the affected patients.
Rational use of medicines (drugs) is such that patients receive drugs in accordance with the clinical need, in doses that meet individual needs, for a set period of time and at the lowest cost to the patients and society. However, every year about 98,000 Americans die because of medical errors of pharmaceutical nature. Each year 1.5 million American become victims of improper use of drugs in form of drug intoxication and allergies, about seven thousand of them die because of the mistakes of medication error. Moreover, treatment of each American patient in a hospital is followed by on average one medication error per day. Over the past two years, 34% of patients seeking help from an American physician, faced with the fact that they were administered the wrong treatment or discharged unnecessary medicines.
The System Factors Influencing Organizational Performance
In the US, surgical procedures might be compared to a pipeline. As with any pipeline, there may be fails, especially since its main operating units are people who are prone to make mistakes because of high intensity of labor. However, regarding both wrong-site surgery and medication errors, it can be noted that too much emphasis is placed on individuals and education. Recurring problems appearing with different people should be associated with an imperfect error warning system in the hospitals, but not with a specific person. An analysis of medical errors discovered that majority of errors occurs where multiple layering of omissions relative to one or more patients occurs. Many experts agree that to change the system units is more important than trying to change the behavior of one or more employees.
Accreditation Standards and Government Regulations
Every hospital is obliged to scrutinize every case of improper surgery to determine the sequence of events that led to them. Most cases of wrong-site surgery occur in ambulatory surgical centers. People are simply mixed in these places, surgeons are very busy, and patients are anesthetized before finding out who, what operation and where it is necessary to conduct. Although there are a lot of reasons, one of them is a tendency to increase the number of complex and emergency operations. The government regulation forces hospitals to investigate every case and provide detailed reviews in order to decrease this number.
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With regards to medication errors, the modern definition of the rational use of drugs was approved at an international conference in Kenya in 1985. In 1989, the International Network for Rational Use of Drugs was founded. It was established to guide interdisciplinary research projects that promote more effective use of drugs. Subsequently, the indicators to study the use of drugs in primary health care have been developed. To date, there are still many gaps in accreditation standards and government regulations about the most effective policies and strategies for improving the use of medicines and prevent the wrong-site surgery.
The Role of the Quality or Risk Manager in Addressing the Issues
In medical practice, practically anything may happen. Physicians should remain vigilant, and discuss the potential problems with colleagues. It is possible to avoid gross medical errors in case the clinic would maintain a systematic approach to improve communication between its employees. When scheduling a surgical operation, the quality or risk managers must take into account the composition of the team of surgeons, their professional workload, as well as evaluate the level of fatigue for each doctor who will operate on a patient. The need to constantly be reinsured not yet reached the health care system. There is a need for a manager, who is able to analyze the system and fix it.
Processes and Techniques Which Can Be Used to Investigate, Prevent, and Control These Types of Events Now and in the Future
Hospitals require simple measures that would significantly reduce likelihood of errors. Currently, each clinic has representatives, specifically training the new rules of preparation of the patient for surgery. The hospital should introduce a mandatory procedure for confirmation of the surgical site, which must be conducted immediately prior to surgery. Surgeons should be tested by the same criteria as pilots before the flight. Before a surgery, the upcoming intervention and patient should be checked for the match, whether or not it is that client, and that part and side of body and manipulation.
Three basic rules before start of a surgery must be met. First, the surgeon should mark the place of a future cut with a permanent marker before the patient begins to receive anesthesia and is therefore conscious. Next, the surgeon must not attach any letters or marks on those areas that are not going to be operated. It is better to designate the affected area not by some sort of meaningless crosses, but by initials of the doctor. Finally, immediately before the operation, all surgical team should suspend all their functions for a moment, re-check the accuracy of the intentions, and come to a unanimous agreement on the procedure that they are going to perform and on what part of the body. In addition, one of the hospital doctors should attend all neurosurgical operations for proper control. In addition, before the surgery, the doctor and nurse have to fill out a special form, so as not to confuse the patient, type of surgery and the affected side.
To improve use of medicines, a number of activities should be conducted. The global use of medicines and pharmaceutical policies must be monitored by an organization such as WHO. It should provide policy guidance and support to countries in monitoring the use of medicines, as well as the development, implementation, and evaluation of national strategies to promote rational use of medicines. In addition, software for the national training of health professionals in monitoring and improving the use of medicines at all levels of the health system should be developed and distributed. After all that, health care workers can hope that these actions will decrease the frequency of complaints. In case of disagreement with new rules, doctors would lose their license and the hospital should be denied accreditation.
Possible Measures to Assess the Problem and the Risk Management Plan
In the US, surgical operating may become safer in terms of operation on the other (healthy) parts of the body. For this purpose, a number of measures should be implemented. A special organization must exist, which would have the purpose of data collection on the errors. It should put forward recommendations to hospitals to avoid such tragedies in the future. Such an organization should require hospitals to analyze their weaknesses in order to be able to identify where there are shortcomings and correct them. It should also control general hospitals, ambulatory surgical centers, and long-term monitoring centers.
American Academy of Orthopaedic Surgeons has shown a good example of the risk management plan in this area as it relates to patient safety. In 1997, it launched a program called "Look at your side". Under this program, a surgeon should talk to his/her patient immediately before surgery, tell the patient about the planned operation, and mark the surgical area, usually on the limbs, with an indelible marker.
Impact These Events Have on Organizational Performance, Compliance, and Accreditation
Medical personnel are responsible for the consequences of the acts committed. What penalty the organization will receive depends on the severity of the damage caused to the patient. A physician who has made such a mistake is exposed not only to ethical and moral evaluation from others, but is also subject to civil, legal, and sometimes even the criminal liability.
Another consequence is litigation with patients. US patients turn to a court approximately 10 percent of medical errors. The percentage of lawsuits related to the wrong choice of the surgical site is small. However, almost all patients win in court. In some cases in which error is negligence in the walls of the operating room, doctors lose their licenses to hospitals are denied accreditation and are forced to pay for moral damages of their affected patients.
Any practice is fraught with errors. However, there are areas where mistakes are simply not acceptable, and medical practice is one of such cases. Physicians are ordinary people who might make mistakes in their work. However, a medication error, as well as wrong-site surgery, can be fatal for the victim. These sad events occur even in the most highly trained specialists in the expensive and advanced clinics. Both of these events cause pretty terrible consequences, and their price is high and extremely harmful to the patient and hospital.