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Cutting Down On Medical Errors

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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.

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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