To Err Is Human

[Guest guest]

Wikipedia provides a good summary of the IOM report

http://en.wikipedia.org/wiki/Medical_error

System and Process Design

In 2000, The Institute of Medicine released " To Err Is Human " , which asserts

that the problem in medical errors is not bad people in health care-it is

that good people are working in bad systems that need to be made safer.[9]

Poor communication, unclear lines of authority of physicians, nurses, and

other care providers.[10]

Disconnected reporting systems within a hospital: fragmented systems in

which numerous hand-offs of patients results in lack of coordination and

errors.[11]

The impression that action is being taken by other groups within the

institution.

Reliance on automated systems to prevent error.[12]

Inadequate systems to share information about errors hamper analysis of

contributory causes and improvement strategies.[13]

Cost-cutting measures by hospitals in response to reimbursement

cutbacks.[14]

Environment and design factors. In emergencies, patient care may be rendered

in areas poorly suited for safe monitoring. The American Institute of

Architects has identified concerns for the safe design and construction of

health care facilities.[15]

Infrastructure failure. According to the WHO, 50% of medical equipment in

developing countries is only partly usable due to lack of skilled operators

or parts. As a result, diagnostic procedures or treatments cannot be

performed, leading to substandard treatment.

The Joint Commission's Annual Report on Quality and Safety 2007 found that

inadequate communication between healthcare providers, or between providers

and the patient and family members, was the root cause of over half the

serious adverse events in accredited hospitals.[16]

Other leading causes included inadequate assessment of the patient's

condition, and poor leadership or training.

==

So I think it behoves us to pay close attention and watch over our loved

ones when in hospital.

All the best,

~ Karl

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