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Making Hospitals Own Up to Their Mistakes

Despite the fact that 98,000 people die each year from medical errors, hospitals are not required to tell patients and their families when a medical error occurs.

On July 1, new patient safety standards go into effect that will require hospitals to initiate specific efforts to prevent medical errors and to tell patients when they have been harmed during their treatment. Dr. Dennis O'Leary is president of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), a nonprofit group that accredits 80% of the nation's hospitals and that issued the new standards. O’Leary talked with the Early Show about what the new standards mean.

The medical community is scrambling to try to make healthcare safer, but the effort has been frustrated in part because of the way errors are handled. When a mistake is made today, there is no legal requirement that a patient be told. The result is that those close to the error know of the mistake, but the event is kept secret. So, researchers say, common mistakes--such as administering a drug incorrectly--are rarely identified quickly and studied for ways to make the healthcare system safer.

"Healthcare executive, physician, and nursing leaders must radically change their thinking about medical mistakes," says O'Leary. "We need to create a culture of safety in hospitals and other healthcare organizations in which errors are openly discussed and studied so that solutions can be found and put in place. These new standards are intended to do just that."

According to JCAHO, the new standards underscore the importance of strong organization leadership in building a culture of safety. Such a culture should strongly encourage the internal reporting of medical errors and actively engage clinicians and other staff in the design of remedial steps to prevent future occurrences of these errors. The additional emphasis on effective communication, appropriate training, and teamwork found in the standards language draw heavily upon lessons learned in both the aviation and healthcare industries.

A second major focus of the new standards, according to JCAHO, is preventing medical errors through the prospective analysis and redesign of vulnerable patient care systems (for example, the ordering, preparation, and dispensing of drugs). Potentially vulnerable systems can readily be identified through relevant national databases such as JCAHO's Sentinel Event Database or through the hospital's own risk management experience.

The new standards are based both on JCAHO's own 6-year experience in overseeing the management of medical mistakes in accredited organizations and on the opinions of a special panel that included patient safety experts as well as leaders from government, hospitals, insurance companies, universities, and consumer advocacy groups.

"These standards are meant to create a culture of safety," says O'Leary. "Errors are not reported inside organizations because careivers are fearful they will be punished," he says. The new standards are designed to promote open discussion and review of errors so that fixes can be found and applied. O'Leary says that with the new standards a hospital could get in more trouble for not looking for errors than by committing them. "If we can save a lot of lives by making some basic changes in patient care processes, it will be a wonderful benefit," he says.

The American Medical Association, which has an ethical standard that says doctors should always tell patients about medical errors, applauds the commission's new standards.

O'Leary says that "to create a culture of safety, caregivers must feel safe that they are not going to be punished and that the system is designed to protect them when they do make a human error."

He adds that although these standards are just now being implemented, it has been part of the AMA code of ethics for doctors to inform their patients when a mistake has been made and thahe believes most physicians abide by that code.

O’Leary says the problem is both litigation and professional embarrassment. The implications for litigation are tremendous when a medical mistake is made. Also, the caregivers feel terrible when they make mistakes and are afraid of revealing the mistake to peers. But he points out that in instances where patients are told of mistakes litigation actually goes down. That's because if patients are suspicious and think someone is hiding something they get upset and want to sue. If they are told the truth and get all the information about the mistake they tend to not be as angry and to not sue as frequently. He says litigation is usually the result of bad communication. These new standards put in place a communication system between hospitals and patients.

Protecting healthcare professionals if they come forward is the best way to encourage them to report mistakes in the first place. That sort of leadership must come from the senior management of a hospital or healthcare organization according to O'Leary. The CEO has to walk the walk and talk the talk when it comes to being open about mistakes and how to prevent them. People are going to make mistakes. The best way to prevent them is to create an open system that protects employees and encourages them to come forward when a mistake occurs or when they feel there is a problem with a medical procedure or medication.

So, how can you protect yourself and your family from medical mistakes? Simple--pay attention! O'Leary says ask questions early and often and make sure you get the right answers. If a nurse brings you a pink pill that you've never seen before, ask what it is for and who prescribed it. Is it for the guy next to you? Find out! He also suggests bringing someone with you when you go to the hospital so if you are incapacitated there is someone looking out for your interests.

Doctors and nurses are human. Humans make mistakes. The bottom line is, ou have to learn from your mistakes in order to prevent future ones.
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