Preventable Medical Error 3rd leading cause of death

[guest7/31/17]

John Hopkins recently released a study identifying preventable medical error as the third leading cause of death. Did that statement immediately make you feel angry or conflicted? Not because you believe it's untrue but instead your experience as a hospital nurse may have proven to you it's true.Nurses struggle every day to put their patients first in unsafe environments often permeated with the threat of intimidation, bullying, and retaliation if they speak up. Nurses predominantly live in a culture of fear. We know why patients are often placed at risk. We are the eye witnesses to acts of negligence. Sleepless nights, fear, anxiety disorders. Do you find yourself trapped in a cycle of anxiety knowing what your Nurse Practice Act holds you independently accountable to and yet hospital administration putting you in a position where you can't adhere to your NPA by charting contemperaneosly, giving medications on time, finding someone available to waste controlled substances at the time you withdraw them, preventing failures to rescue, preventing that confused patient from falling while you are beyond busy with a completely unmanageable assignment, or forbid, forbid reporting as is your duty to do a Physcian who consistently practices with reckless disregard? We know the truth. Yet we are afraid to speak up. Afraid of loosing our job or worse finding ourselves charged with a felony like nurses in Texas found themselves when they dared to report a Doctor they had documented evidence of a pattern of malpractice. Years later, their lives destroyed they were vindicated. The end result, securing the cult of silence, changes were made by the Texas Medical Board forbidding anonymous reporting of impaired or dangerous practitioners. You do what you have a duty to do and report and you can be assured of having your career wiped out, blackballed (common practice by hospitals in Texas.) IT MUST STOP, WE MUST START TELLING OUR STORIES ABOUT WHY PATIENTS ARE HARMED OR KILLED IN HOSPITALS while nurses daily try to keep our patients safe. Let's start the conversation now. Tell me your stories. Our patients deserve that we start the conversation.

[JKL33]

What were the most common mechanisms of preventable medical error according to the study you reference?

[Apples&Oranges]

I can't read this. It's a jumbledy mess. Could you please break it into paragraphs? And fix the punctuation and usage? I'll check back in a couple days, cause it seems like you are passionate about it.

[guest7/31/17]

You are correct there are three spelling errors and the fashion is conversational. You may find it more informative to read the research. The literature is replete with this recent finding regarding preventable medical errors. Thank you kindly.

[guest7/31/17]

The researchers caution that most of medical errors aren't due to inherently bad doctors, and that reporting these errors shouldn't be addressed by punishment or legal action. Rather, they say, most errors represent systemic problems, including poorly coordinated care, fragmented insurance networks, the absence or underuse of safety nets, and other protocols, in addition to unwarranted variation in physician practice patterns that lack accountability.

Unwarranted variation is endemic in health care. Developing consensus protocols that streamline the delivery of medicine and reduce variability can improve quality and lower costs in health care. More research on preventing medical errors from occurring is needed to address the problem,” says Makary.

Michael Daniel of Johns Hopkins is a co-author on the study.

I as most nurses I suspect would agree the majority of unsafe conditions placing patients at risk have their inception in the hospital systems. Systems set up and manipulated to create maximum profit while utilizing minimal resources. Examples would be the use of emergency room metrics, failure to enforce specialist such as surgeons are available to come in to attend to patients in need of urgent intervention, deliberate nurse understaffing in a day of a surplus of nurses, boarding critically ill patients in regular ER beds for days, tolerance of horizontal violence, hospitialist covering several hospitals on one shift and often covering remotely even from their home in other cities and the cult of silence enforced by the cycle of intimidation. Consider the Baylor University Hospitals cover up and permitting of a grossly negligent neurosurgeon. Permitting him to harm and disable several patients amongst many reports from other concerned health care providers. Failures to hold him accountable and silencing those speaking up lead to many unnecessary catastrophic outcomes. A not so uncommon culture of cover up in many hospitals. Why???? Protecting profit and reputation of what most hospitals are now, huge coorperations. It's epidemic, pervasive, well protected and killing our patients. The question every healthcare provider must ask themselves is does it matter to them. Do protecting your patients matter enough to you that insist the minimal standard of care is adhered to simply because it is right and our first duty is to the patient....NOT OUR EMPLOYER

[guest7/31/17]

In 2010, the Office of Inspector General for the Department of Health and Human Services said that bad hospital care contributed to the deaths of 180,000 patients in Medicare alone in a given year.

Now comes a study in the current issue of the Journal of Patient Safety that says the numbers may be much higher — between 210,000 and 440,000 patients each year who go to the hospital for care suffer some type of preventable harm that contributes to their death.

That would make medical errors the third-leading cause of death in America, behind heart disease, which is the first, and cancer, which is second

[canoehead, BSN, RN]

If someone is the recipient of a medical error, they have a health problem that brought them to the system.

If someone has a heart attack, the staff miss the opportunity to lyse the clot, and the patient dies, was that a death because of a medical error, or was it a death because of the heart attack? How you define the problem could swing the numbers unreasonably in either direction.

Also, if we report every little thing, it takes up time that nurses don't have. Some people can't even get to pee, they probably can't fill out error forms, though they are most likely to make errors.

If I report an error, and there's a change made, it usually results in an extra form, or screening, or double signing, ie more work. What if we upstaffed by one nurse per shift for a month on every unit, and watch the resulting patient outcomes. I think the extra money spent will come back in fewer errors and patient days...but I've never heard of a hospital that tried upstaffing. It would be a great Nurses' Day gift.

[Ambersmom, BSN, RN]

Theres a great article in Reader Digest from 2015 or 16, talking about Texas board of medicine and their decision to limit malpractice awards. Personally, I haven't seen so much doctors as being the problem but other nurses, and the EMR's. EPIC is a system designed (in my eyes) to create medical errors, I hate it with a passion I cannot even describe. Forget about reporting errors, or other issues. The powers that be will find a way to eliminate you and keep the ones who keep quiet and do wrong. Healthcare is mercenary, and it seems pervasive with a culture of fear of retaliation. The day a supervisor screamed at me about filling out patient safety reports, I did 5 in 2 years, 1 on myself for an error I made, and 3 not my error) were sentinel level events. Rather than trying to fix problems through remedial efforts or education, healthcare instead turns a blind eye on them and eliminates those who were brave enough to report in the first place.

[herring_RN, ASN, BSN]

This is from 2013:

The Ten Most Common Medical Errors in the US

Medical Errors - Ten Most Common Medical Errors in the U.S ]

This from 2016:

5 Common Medical Mistakes to Avoid in the Hospital

From falls, to drug mixups, to a chaotic discharge

By Hallie Levine Last updated: April 10, 2016

5 Common Medical Mistakes to Avoid in the Hospital - Consumer Reports

AHRQ Patient Safety Primer on Medication Errors

June 2017

... While the majority of errors likely occur at the prescribing and transcribing stages, medication administration errors are also quite common in both inpatient and outpatient settings....

Medication Errors | AHRQ Patient Safety Network

[herring_RN, ASN, BSN]

What were the most common mechanisms of preventable medical error according to the study you reference?

I think this is about the study referred to:

Medical Errors Are No. 3 Cause Of U.S Deaths, Researchers Say

The authors, led by Johns Hopkins surgeon Dr. Martin Makary, call for changes in death certificates to better tabulate fatal lapses in care.

In an open letter, they urge the Centers for Disease Control and Prevention to immediately add medical errors to its annual list reporting the top causes of death...

Only Heart Disease And Cancer Exceed Medical Errors As Causes Of Death : Shots - Health News : NPR

The letter:

Hopkins-CDC-letter

[JKL33]

Thanks.

Shojana, K.G. & Dixon-Woods, M. (2016). Estimating deaths due to medical error: The ongoing controversy and why it matters. BMJ Quality & Safety, 26(5). Estimating deaths due to medical error: the ongoing controversy and why it matters | BMJ Quality & Safety

[offlabel]

If we can put aside the hysteria for a moment and consider the rest of the story...

https://www.clinicaladvisor.com/the-waiting-room/future-of-physician-assistant-practice-authority/article/633939/