errors can be prevented
to the Institute of Medicine study, To Err is Human, between
44,000 and 98,000 Americans die each year from preventable medical mistakes
they experience during hospitalizations.
- The most common
medical errors include:
- Improper blood
injuries or death
- Mistaken patient
- The Joint Commission
defines a sentinel event as “an unexpected occurrence involving
death or serious physical or psychological injury, or the risk thereof.
Serious injury specifically includes loss of limb or function. The phrase,
‘or risk thereof’ includes any process variation for which
a recurrence carries a significant chance of a serious adverse outcome.”
Such events are called "sentinel" because they signal the
need for immediate investigation and response.
- While death is
the most tragic outcome, preventable medical mistakes cause other problems
as well. Based upon the findings of a study of two prestigious teaching
hospitals, almost 2 percent of hospital admissions experience a preventable
medication error, resulting in an average increased hospital cost of
$4,700 per admission or about $0.5 million annually per 100 beds.
- The real tragedy
is that most of these medical mistakes are preventable. They are most
often caused by systems that break down and don't support the highly
qualified and dedicated hospital caregivers the way they should.
- While significant
and attracting attention, medication errors aren’t the only types
of medical errors that hospitals need to pay attention to. Based upon
a review of over 1,900 sentinel events reviewed by the Joint Commission
since January 1995:
- Patient suicide
accounted for 16.5% of the errors
complication – 12.3%
surgery – 11.7
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