Last week the World Health Organization released new guidelines for patient safety. Why is this a big deal? Well, back in 2000 the Institute of Medicine released a report documenting the large-scale problem of deaths from medical errors. The report stated that upwards of 100,000 people in the United States were dying each year from errors made by health care professionals.



USA Today followed up on this story in 2005, after a panel reconvened on the issue. Five years after the original report, more people were still dying from medical errors than accidents, breast cancer or AIDS. In that story, researchers partially blamed the insurance system for actually rewarding errors. Incredibly, hospitals can profit by billing insurance companies for more services to fix their own errors ? but insurance companies often will not pay for practices that reduce those errors.

To Err is Human

No profession is perfect and the unfortunate truth is that mistakes are inevitable. But the staggering number suggests there is room for improvement. This is where the new guidelines from the World Health Organization come in. While many of the new recommendations (especially around hygiene safety) are already standard practice in the United States, there are still needs for changes in this country.

The guidelines suggest preventing ?look-alike' and ?sound-alike' medications, better communication when patients are handed from one professional to the next, and assuring medication accuracy.

The problem extends beyond medical errors. Other reports have shown that approximately 4,000 people die each year through the ?proper' use of drugs. Folks taking prescription or over-the-counter drugs for the right reasons still meet their demise. This could be due to allergic reactions or other unexpected complications. Usually these deaths stem from patients on several different medications that weren't fully tested for drug interactions.

A Personal Experience

My own family had a bit of a scare just this last week. Our 10 year old had an allergic reaction to the anti-biotic, amoxicillin, which he was taking for a dental infection. About a week after taking the drug, he broke out in hives all over his body. Luckily, it was all on the outside but sometimes this reaction can cause airway blockage and the inability to breathe.

We immediately took him off the drug, but even then the reaction worsened and we ended up in the emergency room with a very scared little boy. Over a 2-hour period, we saw 2 nurses, a physicians assistant and a doctor ? all independently. They all asked us the same questions and we gave the same answers. You would think that this would lead to the same advice.

However, the PA told us that the rash should certainly not get any worse and if it did, to bring him back in. The doctor told us that the rash could continue to get worse for another week and cover his whole body as a normal part of the progression. Did they talk to each other?

Also, the PA suggested one route of more medication, which the nurse came in an started. But when the doctor followed up she seemed unaware of the medication advice of the PA or the fact that the nurse had just given our son a dose of steroids.

Now, I realize this was an emergency room setting and things are a little crazy ? but it was very unconvincing that he was getting the appropriate treatment and illuminating on how medical errors happen.

The bottom line is that many people put a lot of confidence in what their doctors tell them. After all, they went to school for a long time to learn that stuff and you didn't. Still, you must be willing to ask questions and challenge their authority. If your gut is telling you that something about their advice doesn't quite jive ? then ask. Dig deeper until you get the sense that you should heed their advice ? you might just prevent an error yourself.

Copyright (c) 2007 The Brain Code LLC