Allercy and Asthma Health
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The Official Publication of AAN - MA

"Speak Up" To Prevent Medical Errors

By Frank Sandusky, HCMBA, RRT

Is anyone trying to curb the rising cost of health care? Outside of the tangible costs such as employee salaries and benefits, expensive equipment, and physical plant maintenance, what does drive up health care costs?

The major contributor to rising health care costs is medical errors. Medical errors result in millions of injuries, which in turn result in longer hospital recovery times and billions of dollars annually in increased health care costs. This does not include costs associated with the patients’ loss of wages or productivity.

The Institute of Medicine has estimated that 98,000 hospital patients die every year as a direct result of medical errors. The number of medical errors is equal to six jumbo jet crashes every day. Additionally, the Institute for Healthcare Improvement has indicated that between the years of 2004 and 2006, 238,000 Medicare patients died due to preventable causes. Ten essential medical errors account for these errors:

  1. Medication Errors: According to the National Academies of Science, medication errors are the most common medical errors, harming an estimated 1.5 million people every year.
  2. Poor Communication: Communication breakdown among health care workers affects their ability to properly care for patients.
  3. Infection: Hospital-acquired infections can result in serious complications for patients.
  4. Falls: Surprisingly, the majority of falls are related to the inability to predict how new drugs will affect patients.
  5. Surgical Errors: It is vital to prevent errors before, during, and after surgery. Even with “time outs” in place, wrong site, wrong procedure, and even wrong patient surgeries still occur.
  6. Pharmacy Errors: With dozens of prescriptions to fill each day, pharmacies can make errors on patient medications.
  7. Lab Errors: Given the volume of patients and tests, medical errors can occur. Some of these can be devastating, resulting in wrong diagnosis, wrong treatment, and diseases left untreated.
  8. Treatment Errors: Many physicians have been in practice for decades, and some do not adopt current best practices.
  9. Follow-up Care: Without clear instructions and patient education at discharge from the hospital/clinic to home, patients can become confused about their follow-up care. That confusion can lead to a costly readmission.
  10. Birth Injuries: Medical errors at birth can lead to serious injuries such as cerebral palsy and paralysis.

Patients can “Speak Up”

This brings us back to the original question. Is anyone trying to curb the rising cost of health care? When it comes to preventing medical errors, the answer is yes. The Joint Commission, in cooperation with the Centers for Medicare and Medicaid Services, started the Speak Up™ initiative in 2002. This program endeavors to make the patient an active, involved, and informed participant in their own health care. The program urges patients to take a role in preventing medical errors by “speaking up” when they have concerns about their care. It’s easy, just think of this acronym:

Speak up if you have questions or concerns. If you still don’t understand, ask again. It’s your body and you have a right to know.

Pay attention to the care you get. Always make sure you’re getting the right treatments and medications by the right health care professionals. Don’t assume anything.

Educate yourself about your illness. Learn about medical tests you get and about your treatment.

Ask a trusted family member or friend to be your advocate (advisor or supporter).

Know what medicines you take and why you take them. Medicine errors are the most common health care errors.

Use a hospital, clinic, surgery center, or other type of health care organization that has been carefully checked out. For example, The Joint Commission visits hospitals to be sure they are meeting the Joint Commission’s quality standards.

Participate in all decisions about your treatment. You are the center of the health care team.

A wealth of resources

As a part of the Speak Up program, The Joint Commission has developed a series of brochures and posters. Speak Up posters include:

•        Universal Protocol
•        Speak Up: Five Things You Can Do To Prevent Infection
•        Speak Up: Help Prevent Errors in Your Care
•        Speak Up: Help Avoid Mistakes with Your Medicines

The program also offers brochures for patients receiving services in specific settings, including hospitals, ambulatory care, laboratory, long-term care, behavioral health care, and home care. A total of 18 brochures are available:

  1. What You Need To Know About Breastfeeding
  2. Dialysis—Five Ways To Be Active in Your Care at the Hospital
  3. Help Prevent Errors in Your Care
  4. Five Things You Can Do To Prevent Infection
  5. Tips for Your Doctors Visit
  6. Reduce Your Risk of Falling
  7. Diabetes—Five Ways To Be Active in Your Care at the Hospital
  8. Prevent Errors in Your Child’s Care
  9. What You Should Know about Pain Management
  10. Help Avoid Mistakes With Your Medicines
  11. Help Prevent Medical Test Mistakes
  12. Help Avoid Mistakes in Your Surgery
  13. Planning Your Follow-up Care
  14. Understanding Your Doctors and Other Caregivers
  15. Know Your Rights
  16. Information for Living Organ Donors
  17. What You Should Know about Research Studies
  18. Stay Well and Keep Others Well (Coloring Book)

All of these resources can be downloaded for free from the Joint Commission website at www.jointcommission.org/speakup.aspx. The Joint Commission has also developed six animated Speak Up videos in English and Spanish that talk about how to reduce the risk of falling, helping kids speak up about their care, speaking up at the physician’s office, taking medication safety, and preventing the spread of infection. The videos are also available at the Joint Commission website.

Many hospitals have adopted the Speak Up program or incorporated it as part of their safety program. Over 2,500 hospitals have already used the Speak Up videos.

We can do more

The Speak Up initiatives certainly have the potential to improve patient safety in all health care areas. Many respiratory therapists have already adopted concepts like Time Outs, SBAR (Situation-Background-Assessment-Recommendation), Read Back, and Learn Back in an effort to improve patient safety. Additionally, some respiratory therapy departments have instructed their staff to be proactive by providing you with a list of your breathing medications that explains what the medications do, what time to expect the respiratory therapist, and what adverse effects you might experience.

Some RT departments have also taken a page from the airline pilots’ safety manual: They have developed a safety checklist. The respiratory therapist uses the checklist when you make the transition from critical care to patient care units or from the hospital to your home. These checklists are beneficial to patients being discharged.

It starts with you

About 42% of the U.S. population has directly experienced or been affected by a medical procedure or medication error. Eighty-four percent of the U.S. population has friends or family who have been victims of a medical error. You can be an active participant in medical error prevention by speaking up when you have concerns about your own medical care.

Frank Sandusky, HCMBA, RRT, is a long-time member of the American Association for Respiratory Care. He serves as manager of respiratory care services at the Fairview Hospital, a Cleveland Clinic hospital in Cleveland, OH.

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