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Learning From Our Mistakes 10 Years After To Err Is Human

Cheryl Clark, for HealthLeaders Media, December 2, 2009

But it has helped, Schyve says.

2. Hand hygiene gets much more attention today than it did 10 years ago. Schyve refers to studies showing that health providers wash their hands only half of the times they are supposed to, although they honestly believe they're doing it 90% of the time. Hospital officials moved sinks closer to doors and located hand-gel dispensers everywhere.

But still providers didn't always wash their hands. In some places, investigators who undertook serious efforts to find out why they didn't discovered that caregivers were carrying things when they entered and exited patients' rooms. "Their hands weren't free to use the gel," Schyve says. Now, some hospitals are installing small tables or trays where providers can place things conveniently while they use the dispensers.

Other facilities are trying the use of buzzers that automatically go off when the provider passes a dispenser without using it.

3. Providers have become more comfortable with dealing with the aftermath of a mistake and not ignoring it. "When something goes wrong, they don't just throw up their hands and feel terrible about it, they do a root cause analysis," Schyve says. "They're able to make changes to prevent it from happening again."

He adds providers are doing this today, unlike a decade ago, even when no harm to a patient occurred. It's enough that there was the potential for it to happen to prompt staff to analyze how the mistake occurred.

One example is the potentially fatal error of administering concentrated potassium chloride to a patient. The commission published a sentinel alert and now, potassium chloride is only sent to patient care units after it has been diluted by the pharmacy.

Tall man lettering, the practice of capitalizing key letters to distinguish drug one drug from another that is similarly named to avoid mistaking drugs that look alike and sound alike and not storing them in alphabetical order are other techniques that make mistakes harder to make.

4. Central venous catheter infection checklist protocols have been or are being put in place at many hospitals nationally to reduce this common cause of medical errors that can have lethal consequences.

5. Require nurses and other caregivers to always read back a physician's orders in the doctor's presence. This helps the doctor verify that what he or she said was what was intended, that the receiving caregiver heard it correctly, and both doublecheck that it was properly written down.

6. Using two identifiers to be sure the patient is the correct person. And to avoid mistakes, providers should be making it a routine practice to ask the patient to identify himself or herself. "Don't just go in and say, 'Are you Mrs. Brown?' because the patient might mishear and say yes. Ask the patient to say her name," Schyve says.

There were many other lessons Schyve mentioned. But he made the point. We don't really know if we're doing better, but we probably are. The important thing is that we're now willing to admit we're human, and we err.

And as humans we can recognize that and prevent it.

Other than making sure counts of foreign objects are performed before and after surgery, it's unclear what will work to prevent foreign objects like retractors being left inside surgical cavities.

At least in California, findings of clamps, sponges, hemostats, and towels inside surgical patients who have been closed still pepper the "immediate jeopardy" fines issued against hospitals by the state.

But increasingly, there are more ideas. Some hospitals are tagging surgical objects so an alarm will go off if they leave the suite with the patient. There's an idea to stamp numbers on sponges and towels, so they can be more easily counted when discarded, Schyve says. And some hospitals make it a policy to perform X-rays on certain patients after their procedures to make sure no objects were left inside.

The last time I spoke with Jennings, he had moved to Nashville with family, and still struggled with his recovery. I tried to call him this week, but the old number I have has been disconnected.

I wanted to know what he would say today about patient safety, 10 years after "To Err Is Human." Would he be reassured that incidents like this are much less likely to happen to someone else?


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Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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1 comments on "Learning From Our Mistakes 10 Years After To Err Is Human"


Sherry Chaffin (9/19/2010 at 8:41 PM)
This article written my Cheryl Clark 12/2/2009 is about my cousin, Dan Jennings. I just wanted to add for anyone that may be interested that Daniel passed away on 9/10/2010 in his home in Fredricksburg, TX after 10 years of pain & suffering & depression from this horrible mistake. If you can let Cheryl Clark know, it would be greatly appreciated, as we appreciate her writing this article. Thank You, Sherry Chaffin