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Stunning Medical Mistakes Still Happen 6 Years After Introducing Universal Protocol

According to a report published in the October issue of the Archives of Surgery, introducing the universal protocol endorsed by the Joint Commission in 2004 has NOT reduced the frequency of such medical errors as wrong site surgery or wrong patient surgery, Read a summary of the report.

The protocol requires 3 steps:

  • Pre-procedure verification
  • Marking the correct surgical site
  • Taking a "time-out" for the surgical team just before surgery.

Diagnostic mistakes and poor communication were the primary causes of wrong patient surgery. Errors in judgment and not taking the "time-out" were the primary causes for wrong-site surgery.

But even if the right process is followed, mistakes continue to occur, primarily, according to the study's author, because of "culture", which needs to move from a culture of blame to a culture of patient safety and accountability.

Until that culture change occurs, we all need to arm ourselves, families, and employees with the knowledge of what the protocol should be and holding our providers accountable for using the protocol.

We can also arm ourselves with knowledge about the policies, procedures and outcomes of the hospitals in our community. The Leapfrog Group website reports Memphis-area hospital results on their "never-events" policy, which includes:

  • Acknowledging these types of errors that should never happen;
  • Apologizing to the patient and family;
  • Not charging the patient or insurance company for the error or any cost due to the error;
  • Performing a root cause analysis of why the error occur so that process improvements can be put into place to prevent the error from occurring again; and
  • Reporting the error to proper accrediting and/or licensing authorities.

Check out Memphis-area hospital performance on  "managing serious errors". Delta Medical Center, the Methodist Healthcare hospitals, the MED, the St. Francis Healthcare hospitals, and St. Jude Childrens Research Hospital all indicate that they DO follow the Leapfrog Group policy, The Baptist Memorial Health Care hospitals indicate they DO NOT follow the Leapfrog Group policy.

There is something we as patients and purchasers can do to help decrease medical errors and getting hospitals to implement The Leapfrog Group Never Events Policy is one of them.

Posted by Cristie Travis at 3:25 PM

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