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Creating a world where patients and those who care for them are free from harm

Key Facts About Patient Safety

What do we mean when we talk about patient safety?

Doctors, nurses, and other health professionals dedicate their lives to caring for their patients. But providing health care can be complicated. There are often multiple steps involved in a health care visit. A number of different medical staff may be take part in the care of a single patient. And patients may be confused by unfamiliar words and technical language.

Although hospitals, clinics, and doctor’s offices take many steps to keep their patients safe, medical errors can happen. Often, medical errors (also called adverse events) happen when there is a single misstep in a chain of activities.

Researchers and experts in the field of patient safety have identified a number of ongoing patient safety challenges. Below are descriptions of some of the most common and worrisome issues.

Wrong-Site Surgery | Medication Errors | Health Care-Acquired Infections
Falls | Readmissions | Diagnostic Error

 

Wrong-Site Surgery

Wrong-site surgery means an operation done on the wrong part of the body or on the wrong person. It can also mean the wrong surgery was performed.

Wrong-site surgery is rare and preventable, but it does still occur. Between 1995 and 2010, 956 wrong-site incidents were reported to the Joint Commission (the Joint Commission is an organization that reviews and grants accreditation to health care institutions). One study surveyed surgical procedures from 28 hospitals and found the incidence of WSS to be approximately 1 in 112,994 procedures. For the average hospital, this means only one error every 5 to 10 years.

>> Read more about wrong-site surgery on the Joint Commission website.

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Medication Errors

Medication errors are when a patient receives the wrong medication, or when he or she receives the right medication but in the wrong dosage or manner.

Medication errors are unfortunately very common. According to the Institute of Medicine’s July 2006 report Preventing Medication Errors, medication errors harm an estimated 1.5 million Americans each year, resulting in upward of $3.5 billion in extra medical costs. Medication errors include cases where the wrong medication is given, where the wrong dose of the right medication is given, or when medication is given the wrong way (for example, in pill form rather than liquid) or when it is given at the wrong time.

>> Read more about medication safety.

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Health Care-Acquired Infections

A health care-acquired infection (HAI) is an infection a person gets while being treated for a medical condition. HAIs may occur in patients who are treated at a medical facility or in their homes. An infection is considered to be an HAI when it occurs after treatment begins. HAIs are often discovered within 48 hours of admission to a health care facility, but other infections may also be considered HAIs.

In the United States, 1 out of 20 hospitalized patients contract HAIs. These complications of care lead to extra time in the hospital and longer recovery times.

The three most common types of HAIs are

  • Catheter-related bloodstream infections: Catheter-related bloodstream infections, or CRBSIs, are among the most common infections in patients who are admitted to critical care units. These infections occur when bacteria and other germs travel down a “central line” and enter the bloodstream.
  • Hospital-acquired pneumonia: Hospital-acquired pneumonia (HAP) is an infection of the lungs that occurs 48 hours or longer after admission to a hospital. This pneumonia tends to be more serious because patients in the hospital are often sicker and unable to fight off germs than otherwise health people. Hospital-acquired pneumonia occurs more often in patients who are using a respirator (machine) to help them breathe. Ventilator-associated pneumonia (VAP) falls into the HAP category. It may occur in patients who need a tube to breathe.
  • Surgical site infections (SSI): A surgical site infection is an infection that occurs after surgery in the part of the body where the surgery took place. Surgical site infections sometimes only involve the skin. Others are more serious and can involve tissues under the skin, organs, or implanted material (such as knee or hip replacements).

>> Read more about preventing infections.

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Falls

Falls are a common cause of injury, both within and outside of health care settings. According to the U.S. Centers for Disease Control and Prevention, more than one-third of adults over 65 fall each year. Injuries that result from falls can include bone fractures, excessive bleeding, or even death.

Researchers estimate that more than 500,000 falls happen each year in U.S. hospitals, resulting in 150,000 injuries. Patients may be at increased risk of falls if

  • They have an impaired memory
  • They have muscle weakness
  • They are older than 60
  • They use a cane or walker to help them walk

Medications may also play a role in increasing a person’s risk for a fall. Studies have also shown that elderly patients taking four or more prescription medications are at three time’s greater risk for falls than are other patients.

Hospitals and other health care organizations take steps to prevent falls among their patients. You can help prevent falls by asking your doctor or nurse about your risk and taking steps to reduce your chance of a fall.

>> Read about what patients can do to prevent falls.

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Readmissions

A readmission is when a patient needs to return to the hospital less then 30 days after being discharged. Many factors may lead to hospital readmissions, such as poor quality care or a gap in the transition between different providers and care settings. Readmissions may also occur if patients are discharged from hospitals prematurely, or if they are discharged to inappropriate settings, or if they do not receive adequate information or resources to aid in recovery.

Patients can help avoid readmission by making sure they understand their care plan before they are discharged from the hospital. They also need to be sure to follow up on care once they leave the hospital.

>> Read about what patients can do to prevent readmissions.

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Diagnostic Errors

Diagnostic errors mean a diagnosis that was either “wrong, missed, or unintentionally delayed.” No-fault errors may happen when there are masked or unusual symptoms of a disease, or when a patient has not fully cooperated in care. Diagnostic errors may also result from system-related problems, such as equipment failure or flaws in communication. A wrong diagnosis may also occur when the clinician relies too much on common symptoms, and choosing an obvious answer, without looking further into what may be causing them.

>> View the Checklist for Getting the Right Diagnosis.

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