Final project presentation health language
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Final project presentation health language
- 1. HOW SAFE IS HEALTHCARE DOCUMENTARY HCA/220 - THE LANGUAGE OF HEALTH CARE INSTRUCTOR: JUDY JEAN MAUREEN PELTON DECEMBER 16, 2013
- 3. PREVENTABLE ADVERSE OUTCOMES ARE COMMON IN HEALTH CARE THERE WERE TWO LARGE SEMINAL STUDIES: NY STATE IN 1984 COLORADO AND UTAH IN 1992 KEY RESULTS: MEASURE CO NY PREVENTABLE ADVERSE EVENT RATE 1.5% % THAT CONTRIBUTED TO DEATH 8.8% UT & 2.1% 13.6%
- 7. Types of medical errors: Diagnostic errors Error or delay in diagnosis Failure to use appropriate test Failure to respond to result of test Treatment errors Procedural technical error Medication error Delay in treatment Inappropriate care Preventive Failure to provide preventive treatment Failure to monitor patient
- 8. BETTER UNDERSTAND THE TYPES OF ERRORS HERE IS AN EXAMPLES OF THE COMMON TYPES OF ERRORS ERROR IN DIAGNOSIS 50 YR. BM ADM FOR SPINE FUSION AWOKE FROM SURGERY WITH PARAPLEGIA DX TRANSVERSE MYELITIS TRANSFERRED TO AMERICAN HOSPITAL DX A CUTE SPINAL CORD CVA
- 9. FAILURE TO USE APPROPRIATE TEST 72 YR. WF WITH UTI ON THE NEXT DAY, SHE BECAME SUDDENLY WORSE TRANSFERRED TO ICU COVERING DOCTOR CHANGED ANTIBIOTICS ORDERED GENTAMICIN DID NOT ORDER LEVELS ONE WEEK LATER SHE HAD ACUTE RENAL FAILURE CHART REVIEW - FAILURE TO CHECK LEVEL
- 10. FAILURE TO RESPOND TO RESULT OF A TEST 45 YR. WM ADM FOR LAP NISSAN FUNDOPLICATION POST-OP, HAD DIFFICULTY RESUMING DIET CXR SHOWED FREE AIR UNDER DIAPHRAGM, PNEUMOMEDIASTINUM PT. DISCHARGED WITH MEDICINES FOR PAIN AND NAUSEA RETURNED THREE DAYS LATER WITH MEDIASTINITIS FOUND TO HAVE ESOPHAGEAL LACERATION ON SURGERY
- 11. PROCEDURAL TECHNICAL ERROR OPERATION PROCEDURAL TECHNICAL ERROR - OPERATION 56 YR. WM ADM FOR HERNIA REPAIR DURING SURGERY, RIGHT INGUINAL HERNIORRHAPHY PERFORMED UPON AWAKENING, PATIENT SAYS THAT LEFT HERNIA WAS PROBLEM UPON REVIEW, IT WAS DETERMINED THAT SURGERY WAS DONE ON WRONG SIDE.
- 12. PROCEDURAL TECHNICAL ERROR - OTHER PROCEDURE 40 YR. WM BROUGHT TO THE ER IN CARDIAC ARREST PT. RESUSCITATED, THEN REQUIRED INTUBATION THE INTUBATION WAS PLACED IN ESOPHAGUS PT. DETERIORATED AND REQUIRED REPEAT RESUSCITATION CHART REVIEW SHOWED THAT THE ERROR WAS THE CAUSE OF THE SECOND ARREST
- 13. DELAY IN TREATMENT 56 YR. WF WITH ATYPICAL CHEST PAIN ER WAS BUSY, SO SLOW TO GET INTO ROOM MD DID NOT SEE IMMEDIATELY EKG SHOWED ACUTE MI THERE WAS DELAY IN PROVIDING THROMBOLYTIC
- 14. INAPPROPRIATE CARE 24 YR. WF SEEN FOR NASAL CONGESTION DX AS UPPER RESPIRATORY INFECTION RX AMOXICILLIN FOR THE URI LATER THAT DAY, HAD SHORTNESS OF BREATH IN ER, FOUND TO HAVE ANAPHYLACTIC REACTION CHART REVIEW SHOWED UNNECESSARY ANTIBIOTICS LEAD TO REACTION
- 15. FAILURE TO PROVIDE PREVENTIVE CARE TD IS A 70 YR. WF FOR HIP REPLACEMENT THE SURGERY WAS UNEVENTFUL 3 DAYS POST-OPERATIVELY, SHE DEVELOPED SHORTNESS OF BREATH. ABG SHOWED SIGNIFICANT HYPOXIA CT SCAN SHOWS PULMONARY EMBOLI CHART REVIEW - NO VTE PROPHYLAXIS
- 16. FAILURE TO MONITOR PATIENT FAILURE TO MONITOR PATIENT 76 YR. BF ADM WITH HIP FRACTURE AND ATRIAL FIBRILLATION STARTED ON SEVERAL MEDICINES TO SLOW THE HEART HIP FRACTURE REPAIRED WITHOUT DIFFICULTY IMPROVED AND TRANSFERRED TO REHAB FLOOR NURSES DID NOT MONITOR HEART RATE AFTER THREE DAYS, SHE HAS SYNCOPE FOUND TO HAVE PROFOUND BRADYCARDIA
- 17. CONCLUSION MEDICAL ERRORS ARE BOTH COMMON VARIED UNDERSTANDING IS NECESSARY FOR IMPROVEMENT
- 18. REFERENCES 1BRENNAN, T.A., LEAPE, L.L., LAIRD, N.M., ET. AL., "INCIDENCE OF ADVERSE EVENTS AND NEGLIGENCE IN HOSPITALIZED PATIENTS. RESULTS OF THE HARVARD MEDICAL PRACTICE STUDY I", NEJM 324 (1991), PP 370-376. 2LEAPE, L.L., BRENNAN, T.A., LAIRD, N.M., ET. AL., "THE NATURE OF ADVERSE EVENTS IN HOSPITALIZED PATIENTS. RESULTS OF THE HARVARD MEDICAL PRACTICE STUDY II", NEJM 324 (1991), PP 377-384. 3THOMAS, E.J. STUDDERT, D.M., BURSTIN, H.R., ET. AL., "INCIDENCE AND TYPES OF ADVERSE EVENTS AND NEGLIGENT CARE IN UTAH AND COLORADO," MEDICAL CARE 38 (2000), PP. 261-271. 4KOHN, L., CORRIGAN, J.M., DONALDSON, M.S., EDS, TO ERR IS HUMAN: BUILDING A SAFER HEALTH SYSTEM. WASHINGTON, D.C.: COMMITTEE ON QUALITY ON HEALTH CARE IN AMERICA, INSTITUTE OF MEDICINE. NATIONAL ACADEMY PRESS, 2000
Hinweis der Redaktion
- This presentation is about how safe is healthcare?
- This is a documentary that explores patient safety and the types of problems that can contribute to adverse outcomes.
- There have been many studies looking at patient safety and medical errors, but there have been two major studies that have looked at the overall problem. The first was performed on chart review of 30,000 discharges from hospitals in NY State in 1984. The second looked at 15,000 discharges from hospitals in Utah and Colorado in 1992. The rate of preventable adverse events, or medical error rate, was similar in the two studies: 2.1% and 1.5% respectively. The percentage of the adverse events that contributed to the death of the patient was slightly higher in the NY study, at 13.6%, than the Utah and Colorado study, at 8.8%.
- The Institute of Medicine released a report that summarized many studies regarding medical errors and the impact on the health care system. In reviewing these two studies, the error and death rate were extrapolated to the number of admissions to all of the hospitals in the US.
- The conclusion was that medical errors contributed to the death of between 44,000 and 98,000 people annually.
- These same studies looked at what types of medical errors occurred. Medical errors can be divided into errors related to diagnosis, treatment, or preventive care. Diagnostic errors can be related to making an incorrect diagnosis, the failure to perform an appropriate test, or the failure to respond to the result of a test. Treatment errors can be due to technical errors in performing a procedure, including surgery and anesthesia, medication errors, a delay in treatment, or the provision of care that is inappropriate or not indicated for the clinical situation. Errors related to preventive care include failure to provide preventive treatment or the failure to monitor the progress of the patient. In specific cases, it is possible that the medical error may involve more than one type of error
- The patient was a 50 year old black male admitted for spinal fusion. When aroused from anesthesia, he was found to have paraplegia which did not improve overnight. The surgeon consulted a Neurologist and ordered an MRI of the spinal cord. The patient was diagnosed with transverse myelitis (inflammation of the spinal cord). The patient was not improving and requested transfer to the regional American hospital. At the American hospital, the patient was examined and the MRI reviewed and a diagnosis of an acute spinal cord cerebrovascular accident (stroke) was made. A repeat MRI confirmed progressive changes associated with the cerebrovascular accident.
- The patient was a 72 year old white female admitted with a urinary tract infection. She was admitted and started on antibiotics. On the next day, she was worse, with worsening fever and lower blood pressure. She was found to be septic and was transferred to the ICU. The covering physician started several stronger antibiotics, including gentamicin, but did not order any drug levels. One week later, the patient had reduced urine output and was found to have acute renal failure. Chart review indicated that a failure to check drug levels lead to the development of acute renal failure.
- The patient was a 45 year old white male admitted for a laparoscopic Nissan fundoplication. Post-operatively, the patient has difficulty resuming diet with pain and nausea. Chest x-ray showed free air under the diaphragm, as well as pneumomediastinum and subcutaneous emphysema. The patient was discharged with medicines for relief of pain and nausea. The patient returned three days later with chest pain, fever, and inability to swallow. CT scan showed mediastinitis. The patient was taken to surgery where a laceration of the esophagus was found.
- The patient was a 56 year old white male admitted for inguinal hernia repair. In the operating room, a right inguinal herniorrhaphy was performed without difficulty. Upon awakening, patient says that the problem that he was having was on the left side. Physical examination confirmed that the patient had a left inguinal hernia and it was determine that surgery was done on the wrong side.
- The patient was a 40 year old white male brought to the emergency room in cardiac arrest. The patient was successfully resuscitated and the staff started preparations for transfer to the ICU. The patient required intubation, but the tube was accidentally placed in the esophagus. The patient was receiving no ventilatory support and the error was not recognized until the patient arrested again. The patient was resuscitated again, the tube removed and placed correctly. Review of the chart demonstrated that the error in intubation lead to the second cardiac arrest.
- The patient was a 56 year old white female who presented to the emergency room with atypical chest pain. The emergency room was busy, so there was a wait for the patient to be placed in a room, a delay in being seen by the physician, and a delay in getting an EKG. The EKG showed the patient to have an acute myocardial infarction. Once the EKG was done, appropriate care was started, but there was a delay in the appropriate care.
- Patient was a 24 year ole white female seen in the office for nasal congestion. The patient was diagnosed with an upper respiratory infection and prescribed amoxicillin. Later that day, she developed sudden shortness of breath and presented to the hospital. In the emergency room, she was diagnosed with an anaphylactic reaction. On chart review, it was determined that there was no indication for the amoxicillin and that the allergic reaction was avoidable had the antibiotic not been prescribed.
- TD is a 70 year old white female admitted for routine hip replacement. There was no problem in performing the surgery and the patient was doing well for the initial post-operative period. However, on the third post-operative day, the patient started having severe shortness of breath. An arterial blood gas showed that there was significant hypoxia. A CT scan showed multiple pulmonary emboli. On chart review, it was identified that the patient did not receive appropriate venous thromboembolism prophylaxis.
- The patient was a 76 year old black female admitted with a hip fracture and found to have atrial fibrillation with a rapid ventricular response. She was started on several medicines to slow the heart, then had repair of the hip fracture without difficulty. Post-operatively, she did well and was transferred to the rehabilitation floor. Nurses did not monitor the heart rate. After three days, the patient had a syncopal episode. She was found to have profound bradycardia, which improved after adjustment of the dose of the medicines.
- In conclusion, medical errors within our health care system are common and the types of medical vary significantly, depending upon the clinical circumstances. It is only with a better understanding of the frequency and nature of medical errors that improvement can be made in preventing medical errors and improving patient safety.