Erroneous Treatments Then & Now, Have Things Really Changed?

[DoGoodThenGo]

Was up late last night watching the film "The Hospital" from 1971 on television.

Set in a urban hospital of the period (location for the hospital scenes is the Metropolitan Hospital which is still on the UES of Manhattan), the place is plagued by a series of patient deaths not caused by disease, but rather the treatment and or care provided by the doctors and nurses. Meds are administered to anyone who happens to be in a bed or on a stretcher regardless of if it is the correct patient. Patients sent to operating theaters for incorrect surgery, and found in waiting rooms dead of natural causes, that sort of thing.

Now this was in the early 1970's were sadly art did reflect real life in that such errors were common and sadly all to frequent in some places. However we still hear of the same sort of things happening today with adverse outcomes ranging to the most serious (death). Healthcare in the United States sill has a very unacceptably high medical/nursing error rate resulting in 210,000 deaths in 2013 alone.

Does anyone think the errors today have different causes from those say in the 1970's through 1980's. The nursing profession today is nothing like it was back then, but yet something still seems to be missing in that "simple" errors such as "Five Rights" mistakes, operation on wrong part of the body, and so forth still continue to occur.

[Muser69]

I just read about a pennsylvania patient dying from an incorrect blood transfusion. How does that happen?

[ICURN3020]

I believe almost all of these type of incidents are related to breakdowns in communication.

[Anna S, RN]

I think a lot of errors nowadays are caused by short staffing, and by how complex so many things have gotten.

[annie.rn]

I just read about a pennsylvania patient dying from an incorrect blood transfusion. How does that happen?

I worked in a hospital where the same thing happened and I was indirectly involved. It happened b/c the tech who drew the blood for the Type & Cross drew the sample from the patient's roommate but labelled it with the patient's information. The T&C form had to be signed by two people saying that they verified the patient information (checking I.D. band and asking the pt. to verify name and D.O.B.). Two people signed but obviously did not check.

Seems that when humans are involved, there is ALWAYS a way for a breakdown in a process to occur. Sadly, nothing is ever completely foolproof.

[dudette10, MSN, RN]

I know of a situation in which two tele monitors taken into the room on two admits, but box information switched when entered into the monitoring system. One of the patients was having some serious ectopy, a rapid response was called, and the patient was taken to ICU. Only when the monitor was removed from the patient was the error noticed. The patient still in the tele room was the one having the ectopy! After that, only one tele box could be given to an individual nurse at a time.

[ChristineN, BSN, RN]

I know of a situation in which two tele monitors taken into the room on two admits, but box information switched when entered into the monitoring system. One of the patients was having some serious ectopy, a rapid response was called, and the patient was taken to ICU. Only when the monitor was removed from the patient was the error noticed. The patient still in the tele room was the one having the ectopy! After that, only one tele box could be given to an individual nurse at a time.

So each nurse can only have 1 tele pt in their assignment? What happens if there are a lot of pts needing tele on the floor?

[dudette10, MSN, RN]

So each nurse can only have 1 tele pt in their assignment? What happens if there are a lot of pts needing tele on the floor?

Oh, no, sorry I wasn't clear. The nurse asked for two boxes from the monitor tech at the same time. She took both boxes into the room and placed them on the patients. The box information got switched.

Now, you can obtain only one tele box, place it on the patient, and you have to go back to get a tele box for a second patient.

[Esme12, ASN, BSN, RN]

The only thing we haven't modified to a great degree....and it was as common then as it is now....HUMAN ERROR.

[RNsRWe, ASN, RN]

For every expected situation there is an anomaly. For every rule there is an exception. For every failsafe....there is a fail.

[Ruby Vee, BSN]

I just read about a pennsylvania patient dying from an incorrect blood transfusion. How does that happen?

It happens because people take short cuts, or because they don't communicate effectively.

A few decades ago, when I was still on orientation at a new job (but had years of experience), one of the senior nurses at that facility asked me to check blood with him. "OK," I said, hopping off my stool at the nurses station and preparing to follow him into the patient's room.

"Oh, no," he said. "We can check it here in the hallway against the addressograph plate."

"I'm sorry," I said. "I'll go in the room and check the blood against the arm band, but I won't check it here in the hallway." We went into the room, checked the blood and hung it. The next morning I heard in report that Mrs. Thomas had died after receiving Mr. Thompson's blood. I panicked, thinking that it was the blood I had checked with the senior nurse. It wasn't. He had checked the second unit with another new nurse who didn't have the nerve to stand up and do the right thing.

Ten years later, he repeated the exact same error with another brand new nurse.