By Catherine D. Bertram, Partner
"No adverse event should ever occur anywhere in the world if the knowledge
exists to prevent it from happening." That is a direct quote from the
Joint Commission, a national organization that accredits more than 16,000 health care organizations
around the country. In fact it is the first sentence in their introduction
to what they have dubbed "9 key patient safety solutions" for health care providers in order to prevent inevitable human errors
from actually reaching patients and thus prevent patient injuries and
death from preventable errors.
Having worked as Director of Risk Management in a major teaching hospital
and having studied patient safety, I can verify that harm to patients
and "near miss” incidents often involve the issues listed by
the Joint Commission below. Those 9 solutions were developed from the
data the Joint Commission has regarding patient injuries, deaths and near misses.
Unfortunately, in the recent past I have represented families and patients
in the DC area who have been harmed or lost their lives at local hospitals
as a result of
medical errors from situations that would fall into the categories listed below. (Also,
see the links for translations of the 9 patient safety solutions for many
other languages at the end of the article.)
"1. Look-alike, Sound-alike medication names
Confusing drug names is one of the most common reasons for medication
errors. With tens of thousands of drugs currently on the market, the potential
for error created by confusing brand and generic drug names is a recognized
risk that has not been solved.
The widespread and continuing failures to correctly identify patients
often leads to medication, transfusion and testing errors; wrong person
procedures; and the discharge of infants to the wrong families.
Communication During Patient Hand-Overs
Gaps in hand-over (or hand-off) communication between patient care units,
and between and among care teams, can cause serious breakdowns in the
continuity of care, inappropriate treatment, and potential harm for the patient.
Performance of Correct Procedure at Correct Body Site
Considered totally preventable, cases of wrong procedure or wrong site
surgery are largely the result of miscommunication and unavailable, or
incorrect, information. A major contributing factor to these types of
errors is the lack of a standardized preoperative process.
Control of Concentrated Electrolyte Solutions
While all drugs, biologics, vaccines and contrast media have a defined
risk profile, concentrated electrolyte solutions that are used for injection
are especially dangerous.
Assuring Medication Accuracy at Transitions in Care
Medication errors occur most commonly at transitions. Medication reconciliation
is a process designed to prevent medication errors at patient transition points.
Avoiding Catheter and Tubing Mis-Connections
The design of tubing, catheters, and syringes currently in use is such
that it is possible to inadvertently cause patient harm through connecting
the wrong syringes and tubing and then delivering medication or fluids
through an unintended wrong route.
Single Use of Injection Devices
One of the biggest global concerns is the spread of Human Immunodeficiency
Virus (HIV), the Hepatitis B Virus (HBV), and the Hepatitis C Virus (HCV)
because of the reuse of injection needles.
Improved Hand Hygiene to Prevent Health Care-Associated Infection (HAI)
It is estimated that at any point in time more than 1.4 million people
worldwide are suffering from infections acquired in hospitals. Effective
hand hygiene is the primary preventive measure for avoiding this problem."
About the author:
Catherine Bertram is board certified in civil trials and was recently nominated as a 2010
Super Lawyer for Washington, D.C. Ms. Bertram has 20 years of trial
experience and is unique in that she was formerly the Director of Risk Management
for Georgetown University Hospital so she brings a wealth of knowledge
to her practice including how hospitals should be run and what doctors
and nurses can do to protect patients. She is a partner with the firm
her practice to the representation of patients and families of loved ones who have
been injured or lost due to medical errors. Ms. Bertram lectures regularly
to lawyers and health care providers, nationally and locally, regarding
patient safety, medical negligence and other related issues. She has also
recently published a chapter in a medical textbook. She can be reached
by email at email@example.com or by phone 202-822-1875 in her office
in Washington, D.C.