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View Full Version : Lessons From America's Safest Hospitals



Janis.Y.Chen
Thu 4th April '13, 12:33am
In November 4, 2004, Mary McClinton, a beloved 69-year-old social worker and mother of four, checked into Virginia Mason Medical Center in Seattle for a relatively complex but routine procedure to treat a brain aneurysm. Doctors planned to inject her with a contrast dye to help them guide a stent into her brain, via a catheter in her leg, to repair the aneurysm. Instead, they injected her with an antiseptic — a topical cleaning agent — that had been stored in an unlabeled container on the same tray as the dye. The antiseptic blocked the flow of blood in her leg, which swelled to twice its normal size.

Within hours, McClinton's blood pressure dropped, her kidneys failed and she suffered a stroke. As the toxin coursed through her system, her other organs began to fail as well. Nineteen agonizing days later, surrounded by her grief-stricken family and friends, Mary McClinton died, her son Gerald holding her hand.

Tragically, McClinton's case is far from unique. An estimated 6,000 "never events" — egregious errors like operations on the wrong limb or instruments left inside a surgical wound — occur every month among Medicare patients alone, according to a report from the U.S. Department of Health and Human Services (HHS). The total number of preventable errors is far higher — some studies suggest that up to a third of all hospital admissions result in harm to a patient. And a 2010 study from HHS estimates that 180,000 Medicare beneficiaries die every year from accidents and errors.

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Medication errors

About 400,000 drug-related injuries occur each year in hospitals, according to an Institute of Medicine study. To help solve the problem, many of the safest hospitals have embraced the use of a computerized provider order entry (CPOE) system, which forces doctors to enter prescriptions into the computer electronically. "It basically eliminates transcription errors," says Anthony J. Ardire, M.D., senior vice president for quality and patient safety at Lehigh Valley Health Network in Allentown, Pennsylvania.

The system also has built-in safety alerts — for example, it won't allow doctors to prescribe more medicine than is generally recommended. Since implementing the system and introducing bar coding, in which a patient's bracelet is scanned to ensure the right patient is getting the right medication at the right dose, Lehigh Valley's medication-error rate has been reduced from 2 in 100,000 doses to 2 in 1 million doses.

For mor information please check at http://www.aarp.org/health/healthy-living/info-04-2013/safe-health-care.html?intcmp=ATMBB1