Medical Errors in Hospitals
Posted by Holly Haines on March 16, 2010
There used to be very little middle ground in assigning blame when it came to dealing with medical errors in hospitals. Either blame was assigned to an individual or blame was assigned to the system. Now, a new model is being proposed that tries to find a middle ground in assessing blame when a medical error occurs in a hospital setting.
Just Culture, a new model developed by engineer David Marx, tries to bridge that gap and assess blame more accurately in order to such errors in the future. In its April edition, the Joint Commission Journal on Quality and Patient Safety examines one fatal medical error in order to show how difficult this process can become. The article focuses on one particular medical error in order to assess what went wrong and how the error can be avoided.
Four years ago, a nurse at St. Mary's Hospital in Madison Wisconsin mistook a bag of epidural painkiller for penicillin and hooked the wrong bag and hooked the painkiller into the IV of a 16 year old girl about to deliver a baby. The girl's heart collapsed and died. Fortunately, the baby was delivered unharmed. Subsequently, the nurse was fired and later criminally prosecuted for the error.
A later study led by researchers at the Safe Medication Practices concluded that the case involved both human error and systemic flaws that led to the young girl's death. The study found that the nurse failed to place an identification bracelet on the patient designed to match the right patient with the right medication. But the bar coding had flaws and many nurses in the hospital bypassed the procedure. The study also showed that fatigue played a factor in the case. The nurse in question had worked two consecutive 8 hour shifts the day before and had spent the night in the hospital before coming on duty the next morning. The hospital had no rules from preventing overwork such as in this case.
In this particularly tragic case, both human error and system flaws led to fatal medical errors. Blame was assigned to the nurse without properly determining systemic flaws in the hospital. Yet, both contributed to the fatal medical error. Both have to be addressed if such medical errors are to be avoided in the future.
Just Culture, a new model developed by engineer David Marx, tries to bridge that gap and assess blame more accurately in order to such errors in the future. In its April edition, the Joint Commission Journal on Quality and Patient Safety examines one fatal medical error in order to show how difficult this process can become. The article focuses on one particular medical error in order to assess what went wrong and how the error can be avoided.
Four years ago, a nurse at St. Mary's Hospital in Madison Wisconsin mistook a bag of epidural painkiller for penicillin and hooked the wrong bag and hooked the painkiller into the IV of a 16 year old girl about to deliver a baby. The girl's heart collapsed and died. Fortunately, the baby was delivered unharmed. Subsequently, the nurse was fired and later criminally prosecuted for the error.
A later study led by researchers at the Safe Medication Practices concluded that the case involved both human error and systemic flaws that led to the young girl's death. The study found that the nurse failed to place an identification bracelet on the patient designed to match the right patient with the right medication. But the bar coding had flaws and many nurses in the hospital bypassed the procedure. The study also showed that fatigue played a factor in the case. The nurse in question had worked two consecutive 8 hour shifts the day before and had spent the night in the hospital before coming on duty the next morning. The hospital had no rules from preventing overwork such as in this case.
In this particularly tragic case, both human error and system flaws led to fatal medical errors. Blame was assigned to the nurse without properly determining systemic flaws in the hospital. Yet, both contributed to the fatal medical error. Both have to be addressed if such medical errors are to be avoided in the future.
Contact Holly Haines:
1-800-662-6230 or hhaines@arbd.com
