Written by Intern Kara
Similar to hospitals, health care facilities are considered one of the safest places to go for emergency situations and other health-related concerns. Hospitals may be private or federal funded and are fully equipped with different state of the art life-saving apparatus. These efficient man-power materials allow health care facilities to handle all sorts of health issues locally and internationally. However patient safety still remains a prevalent issue despite modern technology and a knowledgeable work force.
According to Dr. Emmanuel, L. et al, patient safety is a discipline in the health care industry that applies safety methods to achieve a trustworthy health care delivery system. Furthermore, the authors also stated that patient safety should minimize incidences while maximizing recovery from them. adverse events may result from problems in practice, products, and procedures of systems.
Patient safety is the core principle of every health care organization, whether it is a privately owned or government-funded health care facility.
As a child, I would love going to checkups at the doctor. Although that seems strange, my doctor always made me feel welcomed and knew how to ease tension in the room. It wasn’t until I was in second grade that I had to stay overnight at Children’s Hospital in Washington DC. Since I loved eating spicy foods all the time, I would put hot sauce on almost all my foods. Through unforeseen consequences, I developed a stomach ulcer.
I was so nervous to be in a hospital, but the doctors and nurses made me feel comfortable and relaxed. Since I was so young, I wasn’t able to remember all the major details. Nevertheless my parents seemed thankful for everything the doctors and nurses were doing to make me better. My mother now tells me that doctors were very careful and precise on all the medication I was given. If my parents had questions or concerns about a certain medication or procedure, they were given the best possible explanation.
With that said, the goal of patient safety is to minimize incidence and to ensure the well-being of each individual patient.
In addition, patient safety issues do not only cover medication errors; patients are not only harmed by the misuse of technology, they can also be harmed by poor communication or delays in receiving treatments.
In the United States, researchers have listed the prevalent patient safety challenges that need immediate attention to protect every patient seeking medical help:
Wrong-Site Surgery (WSS) – the operation was done at the wrong anatomical site, wrong person, or the surgery was performed wrong. Statistics showed that WSS happens in 1 out of 112,994 surgical procedures in 28 hospitals across the United States. This means that WSS happens once for every 5 to 10 years.
Medication Errors – health care personnel’s (nurse or doctor) violated the 5-Rs in medication. (Right – patient, dosage, frequency, route, medication). This very common medication act has resulted to at least $3.5 billion of unnecessary medical cost, according to the 2006 report from the Institute of Medicine.
Health Care-Acquired Infections (HAI) – is a form of infection, bacterial, fungal, viral, etc., that a person contracts while being treated in health care facilities or at home. This type of infection usually occurs within 48 hours from the admission date. According to the Center for Disease Control and Prevention (CDC), approximately 1 out of 20 hospitalized patients will contract HAI. The 2002 report on HAI stated that there were 1.7 million estimated HAIs across the US hospitals, including federal facilities; 417,946 adults and children admitted at the Intensive Care Units (ICU), and 1,266,851 outside the ICU.s, 33,269 and 19,059 for newborns under high-risk nurseries and well-baby nurseries respectively.
Falls –accounts for the most common injury in any health care facility. According to the National Patient Safety Foundation (NPSF), CDC quoted at least more than one-third of adults over 65 years-old fall each year. Furthermore, “Fall” incidents account for at least 150,000 injuries from an estimated 500,000 Fall incident across US Hospitals. Individuals at high risk are those 65 years old and above, those with impaired memory, with muscle weakness and those with an assisstive device, like cane or walker.
Diagnostic Errors –covers a wrong, missed or unintentionally delayed diagnosis. This error can also be due to a system-related problem, like equipment failure, communication error etc. According to the articles published by the Fox News, the financial impact of diagnostic error resulted in at least $38.8 billon of penalty pay-outs between 1986 and 2010.
Readmissions –this is when patients need to go back to the health care facility in less than 30 days from the date of discharge. The reason for the readmission can be due to a breach in the plan of care wherein patients failed to recover at home. The discharge plan of care includes the provision of accurate information on where to get the resources or support group to assist the patient to fully recover. Readmission can also be due to poor coordination or transition affiliate health care providers, where patients receive poor-quality follow-up care after discharge.
In such cases, patients need to be readmitted to get the proper care and adequate discharge plan support. According to the New England Journal of Medicine as cited in the works of Hand, L, in his article “1 out of 7 Surgery patients readmitted with 30 days nationwide” there are more than 13% of patients readmitted within a 30-day period. Cardiovascular related surgery cases and hip replacement alone accounts for 10.5% to17.4% of readmission rates.
AHRQ’s Patient Safety Best Practice
To address these patient safety predicaments, the Agency for Healthcare Research and Quality (AHRQ), identified at least 10 patient safety strategies that can help strengthen the patient safety advocacy across all healthcare facilities in the United States. In their press release this year, AHRQ included the following patient safety recommendation:
- Preoperative checklists and anesthesia checklists to prevent operative and postoperative events
- Bundles that include checklists to prevent central line-associated bloodstream infections
- Interventions to reduce urinary catheter use.
- Bundles including head of bed elevation, sedation vacations, oral care, and endotracheal tubes to prevent ventilator-associated pneumonia
- Hand hygiene
- The do-not-use list for hazardous abbreviations
- Multi-component interventions to reduce pressure ulcers
- Barrier precautions to prevent healthcare-associated infections
- Use of real-time ultrasonography for central line placement and
- Interventions to improve prophylaxis for venous thromboembolisms.
Overall, these top 10 patient safety strategies have a strong chance of improving and saving patients’ lives, which is the most important practice for any health care facility.