Health-care organizations are dealing with the thorny issue of how to handle doctors, nurses and other professionals who make mistakes that harm patients, as I write the Informed Patient column today.
But getting to the bottom of medical errors can be a challenge, since hospitals often keep the details under wraps, and malpractice settlements may put gag orders on all involved.
The latest issue of the Joint Commission Journal on Quality and Patient Safety provides a rare look at the anatomy of one of the most devastating medical errors of the last decade: the death in 2006 of a pregnant teen, Jasmine Gant. She died at St. Marys Hospital in Wisconsin, after nurse Julie Thao, intending to administer penicillin, instead hooked up a look-alike bag of anesthetic - meant to be delivered later by epidural route only - through Ms. Gants IV. The nurse was later dismissed and charged with negligence by the state.
The issue also contains three editorial looking at the broader issue of how medical personnel who make mistakes are treated, including pieces by Harvard University health-policy professor Lucian Leape, systems expert Sydney Dekker and Charles Denham, who co-chairs a National Quality Forum committee on safe practices in care.
St. Marys, which settled a malpractice case brought by the family for a reported $1.9 million, invited the nonprofit Institute for Safe Medication Practices to conduct an independent root cause analyses - a process to identify the factors leading to the error. The paper is worth reading for its insights into the case, but Judy Smetzer, a nurse and vice president of ISMP who led the study, tells the Health Blog the aim in identifying the factors on all sides leading to the error was also to provide lessons that could be used by other providers.
After outlining both safety violations made by the nurse and flaws in the hospital system that contributed to the mishap, for example, the report provides a number of general recommendations that could be used in any hospital where medication mistakes are a danger because of look-alike packaging or a chaotic environment.
For example, hospitals should use different shaped or sized containers to differentiate IV medications from epidurals, or provide epidurals only in syringe form, to be administered by syringe pump. Another strategy: apply big warning stickers on both sides of an epidural bag and over the access port used to spike the bag.
And to avoid confusion and distraction medications should be prepared in a quiet zone, not at the bedside, explaining the importance as a safety move to patients and family.
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