Richard Davis: Working to decrease hospital deaths
Last week the medical community delivered a bit of news that might have surprised some, but not all, of the general public. An article in the British Medical Journal stated that researchers have determined that medical errors are the third leading cause of death in the U.S., behind cancer and heart disease.
The research that was done is questionable at best because data was only extrapolated from hospital records and the figures are considered estimates. There is no cause of death ever listed on a death certificate that says "medical error." The dicey-data researchers came to the conclusion that "... there is an incidence range of 210,000 to 400,000 deaths a year associated with medical errors among hospital patients."
When I read the headline I had hoped to read a report that mentioned some of the reasons for medical errors. Instead what was presented was a superficial statement of a problem; something that has become all too familiar in this bizarre campaign season and not at all dissimilar to a Donald Trump stump speech.
Perhaps there will be more to come from these researchers who have opened up a Pandora's box of speculation. Centuries ago hospitals were places where people went to be comforted as they gasped their final breaths. Today they have become places of cure while the comfort piece seems only an afterthought in too many institutions. The modern hospital has a lot to offer in the way of fixing and curing things but it also is a place of great danger. Anyone with a compromised immune system increases their risk of harm every time they enter a hospital because of the abundance of lethal organisms in the environment. Sure, everything is done to protect patients from the bad bugs, but hospital acquired infections are surely on the list of death causing events in addition to medical errors.
Doctors and nurses are only human and they all make mistakes. Sometimes those mistakes are minor and inconsequential and sometimes they cause death. Health care professionals have to live with the consequences of their actions and that can be a difficult burden to bear. As a nurse, I made my share of mistakes but I don't recall that any of them resulted in death. There was one very close call when I was working as a nursing supervisor and, although it was nipped in the bud, the potential for harm was so great that the near miss still haunts me. An intensive care nurse had to mix up an insulin drip for a very sick diabetic patient. In the off shift hours in small hospitals pharmacists are not always working and nurses have to do the work that pharmacists would do during the day. On this occasion the nurse had to calculate how much insulin to put in a liter bottle of IV fluid in order to deliver a certain number of units of insulin per hour, as ordered by the doctor.
The nurse preparing the drip asked me to check her math to make sure she put the correct amount of insulin in the bottle. We both checked our math at least twice and came up with a number and she proceeded to mix the drip. As I left the unit and walked down the hall I recalculated the math in my head and realized that our calculations would deliver 10 times the amount of insulin ordered. I ran back to the unit and the nurse and I did the math again and she was able to toss out the bottle before any harm was done. That patient would have died in a matter of hours if we had not realized our mistake and it is very likely no one would have figured out the cause of death. I suspect there are a fair number of medical errors that happen this way.
As this medical error story unfolds I hope that researchers take the time to look at the big picture and also get into the weeds on this one so that the number of avoidable hospital deaths decrease over the next years and decades.
Richard Davis is a registered nurse. He writes from Guilford and welcomes comments at firstname.lastname@example.org.
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