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Cutting Down On Medical Errors


Aired 3/22/11

We've all heard the expressions "nobody's perfect" and "everybody makes mistakes." The problem in the healthcare profession is that mistakes can kill.
That's why hospitals are doing everything they can to cut down on medical errors.

— Doctors and other health care providers aren't perfect. They occasionally make mistakes. And the consequences can be devastating.

Pharmacists at Sharp Memorial Hospital fill hundreds of orders a day. They ha...
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Above: Pharmacists at Sharp Memorial Hospital fill hundreds of orders a day. They have to review and approve each prescription.

Dr. Rick Lemoine says in the old days, physicians didn’t want to admit when t...
Enlarge this image

Above: Dr. Rick Lemoine says in the old days, physicians didn’t want to admit when they made a mistake. Now, doctors are up front about it.

Emergency room Director Chris Walker oversees 175 nurses and technicians. He ...
Enlarge this image

Above: Emergency room Director Chris Walker oversees 175 nurses and technicians. He says nurses have to constantly be on their toes, especially when performing routine procedures.

At San Diego's Sharp Memorial Hospital, pharmacist Judy Smith fills hundreds of orders a day.

Smith doesn't want her real name used for fear that someone could identify her. She wanted to talk about an incident at another local hospital where she used to work.

It was Smith's first day on the job. A doctor ordered a high-risk injectible medication for a patient. Smith looked the order over, double checked it, and signed off on it. The next thing she knew, the patient had trouble breathing, and quickly went downhill from there.

"The very first thing that came to my mind is how can it happen?" Smith recalled. "How is this possible? I have approved this medication so many times in my life, and this one time it goes wrong."

As it turns out, the patient was never given the medication. But Smith said the incident made her reevaluate how she does her job.

"Every medication that you validate, there's always this risk associated to it," Smith said. "I guess one of the gifts that I got from this particular event is to really understand that risk."

In 1999 the Institute of Medicine issued a report that shook up the industry. It estimated preventable medical errors kill up to 98,000 Americans every year. Since then, hospitals have gone all out to cut down on mistakes.

Dr. Rick Lemoine is medical director of Sharp Memorial's intensive care unit. He said in the old days, no one wanted to admit when they screwed up. But in recent years, there's been a sea change.

"And the sea change is to be much more upfront," Dr. Lemoine said. "Be completely direct with people as soon as possible after an incident like that has happened, kind of regardless of the severity."

Dr. Lemoine said it's not about blaming anyone. He said a punitive approach keeps things hidden. Lemoine said that's the last thing hospitals want.

"Mistakes are going to happen," he pointed out. "It's my job as a medical director to try and create an environment where mistakes are as infrequent as humanly possible. But when they happen, we need to know about them, so we can try and do something to prevent that mistake from happening again."

Lemoine said most medical errors aren't because of someone doing something bad. Rather, they're due to a system that's poorly designed.

For example, staff figured out that handwritten prescriptions were leading to medication errors.

"When we put in our electronic medical records system," Lemoine said, "just from going from physicians writing to physicians using the computer, our adverse drug events from medication fell by 50 percent in three months. That's the kind of thing we do nowadays."

Sharp department heads get together once a week to discuss mistakes, near misses, and other safety concerns. They also have a monthly meeting that focuses on systemic issues that may lead to errors.

In Sharp Memorial's ER, Director Chris Walker oversees 175 nurses and technicians.

He said mistakes can occur when nurses are performing routine procedures, like putting in an IV.

"Just when you start to feel safe, that's when you're probably most likely to make a mistake," Walker said. "So, it's important to have a healthy amount of fear, as a practicing nurse, a fear that, if I don't watch what I'm doing, I could cause a patient harm."

California regulators penalize hospitals for mistakes that put patient health at risk, or lead to death.

Over the past three years, Sharp hospitals treated nearly 600,000 patients in their emergency rooms, and performed more than 100,000 surgeries. During that time, Sharp reported 16 errors to state regulators. They were fined for three of those.

Kenny Goldberg, KPBS News.

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Avatar for user 'JEC'

JEC | March 22, 2011 at 7:37 p.m. ― 6 years ago

Curious - Americans pay 60% more on health care but we are still dealing with issues such as this. Could it be our system is at fault?

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Avatar for user 'JEngdahlJ'

JEngdahlJ | March 24, 2011 at 9:55 a.m. ― 6 years ago

Where does $20 billion in waste associated with medical errors fit on list of year's big quality 3012stories?

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Avatar for user 'heteromeles'

heteromeles | March 24, 2011 at 5:18 p.m. ― 6 years ago

Interesting hearsay. My best friend also works at Sharp Memorial, and immediately knew who "Judy Smith" was on hearing that clip. While her testimony is compelling, to my knowledge, she is not currently filling "hundreds of orders" per day and has limited experience filling and verifying orders.

While medical mistakes can be a serious problem, so can journalistic mistakes. In the future, please double-check the background and veracity of your sources before you put them on the air.

Note (that I'm willing to verify): aside from my personal connection, I am not an employee of Sharp nor associated with them in any way. I AM, however, a KPBS member, and I am concerned that KPBS airs the best possible reporting.

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