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   A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care   
   James, John T. PhD   
      
   Journal of Patient Safety . 9(3):122–128, September 2013.   
   doi: 10.1097/PTS.0b013e3182948a69   
      
   Author Information   
      
   From the Patient Safety America, Houston, Texas.   
      
   Correspondence: John T. James, PhD, Patient Safety America, 14503 Windy Ridge   
   Lane, Suite 200, Houston, TX 77062 (email: john.t.james@earthlink.net).   
      
   The author discloses no conflict of interest.   
      
   Sources of support: none.   
      
   Abstract   
      
   Objectives: Based on 1984 data developed from reviews of medical records of   
   patients treated in New York hospitals, the Institute of Medicine estimated   
   that up to 98,000 Americans die each year from medical errors. The basis of   
   this estimate is nearly 3    
   decades old; herein, an updated estimate is developed from modern studies   
   published from 2008 to 2011.   
      
   Methods: A literature review identified 4 limited studies that used primarily   
   the Global Trigger Tool to flag specific evidence in medical records, such as   
   medication stop orders or abnormal laboratory results, which point to an   
   adverse event that may    
   have harmed a patient. Ultimately, a physician must concur on the findings of   
   an adverse event and then classify the severity of patient harm.   
      
   Results: Using a weighted average of the 4 studies, a lower limit of 210,000   
   deaths per year was associated with preventable harm in hospitals. Given   
   limitations in the search capability of the Global Trigger Tool and the   
   incompleteness of medical    
   records on which the Tool depends, the true number of premature deaths   
   associated with preventable harm to patients was estimated at more than   
   400,000 per year. Serious harm seems to be 10- to 20-fold more common than   
   lethal harm.   
      
   Conclusions: The epidemic of patient harm in hospitals must be taken more   
   seriously if it is to be curtailed. Fully engaging patients and their   
   advocates during hospital care, systematically seeking the patients’ voice   
   in identifying harms, transparent    
   accountability for harm, and intentional correction of root causes of harm   
   will be necessary to accomplish this goal.   
      
   “All men make mistakes, but a good man yields when he knows his course is   
   wrong, and repairs the evil. The only crime is pride.”— Sophocles,   
   Antigone”   
      
   Medical care in the United States is technically complex at the individual   
   provider level, at the system level, and at the national level. The amount of   
   new knowledge generated each year by clinical research that applies directly   
   to patient care can    
   easily overwhelm the individual physician trying to optimize the care of his   
   patients.1 Furthermore, the lack of a well-integrated and comprehensive   
   continuing education system in the health professions is a major contributing   
   factor to knowledge and    
   performance deficiencies at the individual and system level.2 Guidelines for   
   physicians to optimize patient care are quickly out of date and can be biased   
   by those who write the guidelines.3–5 At the system level, hospitals   
   struggle with staffing    
   issues, making suitable technology available for patient care, and executing   
   effective handoffs between shifts and also between inpatient and outpatient   
   care.6 Increased production demands in cost-driven institutions may increase   
   the risk of preventable    
   adverse events (PAEs). The United States trails behind other developed nations   
   in implementing electronic medical records for its citizens.7 Hence, the   
   information a physician needs to optimize care of a patient is often   
   unavailable.   
      
   At the national level, our country is distinguished for its patchwork of   
   medical care subsystems that can require patients to bounce around in a   
   complex maze of providers as they seek effective and affordable care. Because   
   of increased production demands,   
    providers may be expected to give care in suboptimal working conditions, with   
   decreased staff, and a shortage of physicians, which leads to fatigue and   
   burnout. It should be no surprise that PAEs that harm patients are   
   frighteningly common in this    
   highly technical, rapidly changing, and poorly integrated industry. The   
   picture is further complicated by a lack of transparency and limited   
   accountability for errors that harm patients.8,9   
      
   There are at least 3 time-based categories of PAEs recognized in patients that   
   are or have been hospitalized. The broadest definition encompasses all   
   unexpected and harmful experience that a patient encounters as a result of   
   being in the care of a    
   medical professional or system because high quality, evidence-based medical   
   care was not delivered during hospitalization. The harmful outcomes may be   
   realized immediately, delayed for days or months, or even delayed many years.   
   An example of immediate    
   harm is excess bleeding because of an overdose of an anticoagulant drug such   
   as that which occurred to the twins born to Dennis Quaid and his wife.10 An   
   example of harm that is not apparent for weeks or months is infection with   
   Hepatitis C virus as a    
   result of contaminated chemotherapy equipment.11 Harm that occurs years later   
   is exemplified by a nearly lethal pneumococcal infection in a patient that had   
   had a splenectomy many years ago, yet was never vaccinated against this   
   infection risk as    
   guidelines and prompts require.12   
      
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   METHODS   
      
   The approach to the problem of identifying and enumerating PAEs was 4-fold:   
   (1) distinguish types of PAEs that may occur in hospitals, (2) characterize   
   preventability in the context of the Global Trigger Tool (GTT), (3) search   
   contemporary medical    
   literature for the prevalence and severity of PAEs that have been enumerated   
   by credible investigators based on medical records assessed by the GTT, and   
   (4) compare the studies found by the literature search.   
      
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   Types of PAEs   
      
   The cause of PAEs in hospitals may be separated into these categories:   
      
   * Errors of commission,   
      
   * Errors of omission,   
      
   * Errors of communication,   
      
   * Errors of context, and   
      
   * Diagnostic errors   
      
      
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