Shapiro_DisclosingMedicalErrors2008.doc - This paper was...

This preview shows page 1 - 2 out of 37 pages.

This paper was contracted by the Robert Wood Johnson Foundation. Preliminary interviews were conducted in support of the workshop entitled, “Disclosure: What’s Morally Right Is Organizationally Right,” at the 18th Annual IHI National Forum on Quality Improvement in Health Care, December 10-13, 2006, Orlando, Florida, USA. For more information, contact Eve Shapiro, Medical Writer, at [email protected] Disclosing Medical Errors: Best Practices from the “Leading Edge” By Eve Shapiro Introduction Mary McClinton went into Virginia Mason Medical Center for a relatively routine procedure in 2004. While there she died after receiving an injection of chlorhexidine, a caustic cleaning solution, instead of normal saline. Both were clear liquids and had been placed side by side in unlabelled cups in the operating room. A 9-year-old girl who had just undergone surgery at the University of Michigan Health System in 2001 gave herself a lethal dose of dilaudid because she was given a miscalibrated PCA pump. Betsey Lehman, a Boston Globe reporter, and Maureen Bateman were being treated for breast cancer at the Dana-Farber Cancer Institute in late November 1994. Lehman died on December 3 and Bateman suffered permanent heart damage because, in one day, they received four times the daily dose of the anticancer drug cyclophosphamide. In 1999, the Institute of Medicine shocked the nation by reporting that between 44,000 and 98,000 people die in hospitals each year as a result of medical errors. That report, To Err Is Human , 1 raised awareness about the prevalence of medical errors in our nation’s hospitals. Six years later, in 2006, the Institute of Medicine released the report, Preventing Medication Errors, 2 which revealed that a hospitalized patient can expect to experience, on average, one medication error per day. Dr. Donald Berwick, president of the Institute for Healthcare Improvement, experienced such errors himself when his wife was a patient in a well-known Boston hospital. “It was not just how she was treated,” Berwick told Time magazine, 3 “it was that so little of what happened to her was unusual.” Despite Berwick’s best efforts on his wife’s behalf, he says, “tests were repeated unnecessarily, data were misread, information was misplaced. Things weren’t just slipping through the cracks; the cracks were so big there was no solid ground.” The prevalence of medical errors and their impact on the lives of patients and their families is profound. Why, eight years after the IOM issued its indictment of the health 1 Institute of Medicine. To Err Is Human: Building a Safer Health Care System . Washington, DC: National Academies Press; 1999. 2 Institute of Medicine. Preventing Medication Errors . Washington, DC: National Academies Press, 2006.

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture