That said, we know that the incidence of sentinel events is much higher than it should be. As regularly reported by The Hospitalist, the problem most in the spotlight today—among researchers and the popular press—is medication errors. The IOM report says that, on average, a hospitalized patient is subject to at least one medication error per day, though error rates vary widely among hospitals. Fortunately, most errors cause no serious harm, but the costs for those that do are substantial. One study found that each preventable adverse drug event (ADE) costs a hospital approximately $8,750.
At least a quarter of medication-related injuries are preventable, according to the report. The irony is that many error-prevention methods are available today: “do not use” abbreviation lists; medication reconciliation (used to compare a patient’s medication orders with all other medications the patient is taking in order to avoid omissions, duplications, dosing errors, or drug interactions); and computerized physician order entry systems, to name a few.
With so much emphasis on patient safety and the increasing availability of sophisticated reporting and record-keeping technology, why haven’t incidence rates for ADEs and other sentinel events dropped dramatically? The answer is not that hospital personnel are lazy, incompetent, or indifferent to the safety of their patients. Experts agree that today’s doctors, nurses, pharmacists, and other medical staff are highly trained, dedicated professionals who want to practice the best medicine possible. The present system focuses on individual fault and does not foster disclosure that could lead to corrective procedures.
In fact, legal experts worry that JCAHO’s Sentinel Events Policy, which mandates self-reporting by hospitals accredited by the JCAHO, creates new problems. They suggest that self-reporting will have limited success in the absence of immunity from legal liability. One proposed solution calls for submitting self-regulatory reports to a neutral, nonsanctioning third-party entity. This approach has worked well for the airline industry.
New Patient-Care Focus
Abandoning a policy that concentrates on blame is at the heart of the improvements in patient safety proposed in the IOM report. Rather than pinpointing individual error, the new paradigm focuses on developing new systems of care that foster patient safety and help prevent sentinel events. In the absence of a finger-pointing environment, hospital personnel can freely examine what happened, discover the causes, and structure new procedures to prevent future occurrences – without fear of any retribution.
That’s the way they handle it at California Pacific Medical Center in San Francisco. In one case, when a nurse removed a dialysis catheter, the patient developed an air embolism and subsequently suffered a severe, permanently disabling stroke.
“When we investigated, we found that there was a written procedure in place to document a dialysis nurse’s credential,” says hospitalist Thomas E. Baudendistel, MD, FCAP, who is associate medical director of the hospital’s Internal Medicine Residency Program. “A, we weren’t aware of the credentialing procedure, and B, when we looked at it we weren’t sure it represented best practice. So we researched the literature and rewrote the policy. Now we schedule regular nursing education on pulling a dialysis catheter.”
In addition, the hospital set in place a follow-up plan to re-evaluate the procedure periodically. They also offer refresher training in catheter removal.
“We’ve used a similar approach in other situations,” says Dr. Baudendistel. “For example, our procedure with falls has changed. Now we use an event-based algorithm to determine whether a head CT scan is necessary.”
Hospitalists Can Lead
Hospital-based physicians are in an advantageous position to promote—as well as participate in—new initiatives for patient safety. Because they are involved in the day-to-day care of patients, hospitalists are firsthand observers when many errors occur. They have the experience and clinical judgment to give meaningful input to new incident-reporting protocols and to promote new policies through interdisciplinary teams that investigate and analyze adverse events.