Serious Reportable and Adverse Events in Patient Safety

Hospital Safety Means Reducing Medical Errors

man in hospital bed
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No amount of medical care in the world can improve the health and quality of a patient's life if the approach to care or the environment isn't safe. Hospital safety issues include the risk of medical errors and adverse events or serious reportable events.

As basic as learning to look both ways before crossing the street, or setting your scissors down before you break into a run, are the tenets of keeping infections at bay, double checking drugs before they are administered, even removing or operating on the right body parts.

The National Quality Forum in 2006 listed 28 of these medical errors and called them "never events." They include surgical and device errors, drug errors, care errors, environmental errors and criminal events. Errors resulting from nosocomial (hospital-acquired) infections are not on the list.

A few years later the name was changed from "never events" to "serious reportable events." But the real point remains - they should never happen in a healthcare setting because they put patients at risk of harm and sometimes death.

The Institute of Medicine in 1999 reported the results of two patient safety studies which showed that between 44,000 and 98,000 Americans die each year as a result of medical errors and misdiagnosis, resulting from patient safety problems.

Among the medical errors cited:

  • Hospital and community acquired infections: Hospital patients may develop infections like MRSA or Clostridium difficile, making their illnesses and treatment more difficult. The people most at risk are those with compromised immune systems. This includes people with an open wound from injury or surgery, those who require catheters for drainage or drug delivery, or the elderly whose systems aren't as strong as they used to be. Some infections are called "superbugs" because they have evolved beyond the ability to be killed (eradicated) by existing antibiotics.
  • Drug errors: From problems interpreting a doctor's handwriting on a prescription, to mistakes in their translation at the pharmacy, to administration problems with dosage, time frames or route of administration, to too many similar and confusing drug names, drug errors account for thousands of deaths per year.
  • Surgical errors: Wrong site surgeries and patient misidentification comprise the bulk of surgical errors. Some surgeries don't work as well as the surgeon or patient would like, but that's not the same as one that goes awry, causing an error. Surgeries conducted with heat sources for tasks like cauterizing may also result in fires.
  • Other sources of patient safety problems result in falls, providers who aren't well rested, and other causes. These may also be called "iatrogenic." Find a master list of these never events, adverse events or serious reportable events.

These patient safety violations can take place in any healthcare setting from doctor's offices, hospitals, surgical centers, to long-term care facilities and pathology labs. And because doctors and other providers are taking less time with every patient, they can no longer be counted on to keep us safe in a healthcare environment.

Without being able to depend on providers to keep us safe, patients and their caregivers must make more of an effort to protect themselves from medical mistakes that can lead to death or debilitation.

Here are some ways to protect yourself from medical errors:

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