10 Years After To Err is Human: Are Hospitals Safer?

Foreign bodies, such as sponges, clamps, hemostats, and towels, are too often left inside patients during surgery, because surgical teams don't take seriously enough requirements that they count and record all such items incoming and outgoing.

Infection control lapses
Kathy Warye, chief executive officer of the Association for Professionals in Infection Control and Epidemiology, said a major issue is lack of scientific information about bacterial, viral, and fungal infections that are so frequently transmitted in healthcare settings.

"We don't understand some of these infections, like C. difficile, well enough to know whether they can be prevented," she says. "Science hasn't yet filled the gaps."

Aside from that, she says, another stumbling block is the lack of healthcare executives' support to control preventable infections.

Health executives, she says, "still aren't fully cognizant of what infections ultimately cost," Wayre says. "They look at infection control as a cost center, and in the last economic downturn, 20% of respondents [to a survey] said they had to cut back on surveillance, and 41% said their resources were cut across the board.

Today, 29 states require some public reporting of healthcare infections. And if the current House version of health reform bill passes, it will be 100%.

"Transparency leads to improved outcome, and in many states there is evidence that it's played a key role," Wayre says.

Hospitals need to conduct comprehensive risk assessments to determine if they should be screening patients on admission for infections they may have acquired in their communities, but which could pose serious health issues for other patients, adds Wayre.

Medication errors
It was just two years ago that actor Dennis Quaid's twins were given Heparin in an adult dose that was 1,000 times stronger—rather than the proper dosage of Hep-lock.

Allen Vaida, a pharmacist and executive vice president of the Institute for Safe Medication Practices, says "we have made great strides in understanding that medication errors are an issue, but we still have a long way to go."

Vaida says hospitals should implement barcoding of medications. "Only 5-20% of hospitals now do it. We should be striving for 100%," he says.

Second, he says, "we have to do a better job learning from others." Too many hospitals see tragic mistakes that happen elsewhere and say, "That happened in California. I'm in Ohio. It doesn't happen here.

"We need to realize we're in a risky business, and ask the question 'Could that happen here?' "