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The Centers for Medicare and Medicaid Services (CMS) has adopted the National Quality Forum’s (NQF) list of hospital mistakes that cause the deaths of 200,000 people per year and catastrophic injury to 600,000. Therefore, the fact that no one has mentioned one word about patient safety in the entire health care reform debate is bizarre and shameful. I have presented a simple way to avoid each of the listed fatal errors to demonstrate how simple it would be to make patient safety the main issue of health care reform:
Surgical Events
- Surgery performed on the wrong body part
Nurses are suppose to mark the surgical area with a skin marker during the pre-operative visit
- Surgery performed on the wrong patient
Operating room nurses should visit their patients before the surgery date and make a photographic identification
- Wrong surgical procedure on a patient
The signed consent must be present in the operating room and the patient or family member must state the name of the procedure
- Retention of a foreign object in a patient after surgery or other procedure
The surgeon should never close the patient before verifying that the sponge, needle and instrument counts are correct; they all have to be counted before the procedure and just before closure to make sure that all objects have been retrieved.
- Intraoperative or immediately post-operative death in a normal-health patient (defined as a Class 1 patient for purposes of the American Society of Anesthesiologists patient safety initiative
The anesthesiologist is required to make certain the patient receives adequate oxygen to the brain, and the surgeon and circulating nurse are required to measure blood loos during surgery.
Product or Device Events
- Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility
The hospital must test blood products for infection such as aids and hepatitis.
- Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended
Nurses are not allowed to use gauze rolls as restraints, for example.
- Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility
Nurses must check intravenous tubing for air content and they must prime the tube with the solutions before attaching the tube to the bag or bottle.
Patient Protection Events
- Infant discharged to the wrong person
Security must check infant identification at the door of the hospital
- Patient death or serious disability associated with patient elopement (disappearance) for more than four hours
Nurse should never wait as long as four hours to check on the whereabouts of their patients. Furthermore, all patient’s must be assessed as to mental competence upon admission to determine who is at risk.
- Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility
Nurses must perform risk assessment upon admission and at least once every day. Patient rooms must be rendered suicide proof.
Care Management Events
- Patient death or serious disability associated with a medication error (e.g., error involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration)
Nurses must follow medication protocols without exception, which includes checking the Kardex against doctors orders. Nurses must also guard against polypharmacy reactions by checking with pharmacist for risk of drug interaction.
- Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood products
The must be two nurses to check the product against the patient’s blood type to make certain that they match.
- Maternal death or serious disability associated with labor or delivery on a low-risk pregnancy while being cared for in a healthcare facility
The nurse must watch the fetal monitor at all times for indications of fetal distress during contractions.
- Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
The nurse must be certain that the patient has eaten sufficient quantity before administering insulin and the nurse must also be aware that long acting insulin peaks in six hours.
- Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates
The nurse must check for blood bilirubin levels in all newborns.
- Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
The nurse must provide a risk assessment and follow standard pressure ulcer prevention protocols which includes but is not limited to turning the patient every two hours without fail and keeping the skin clean and dry at all times.
- Patient death or serious disability due to spinal manipulative therapy
The hospital administration must make certain only those who are qualified by both education and experience may perform spinal manipulations.
Environmental Events
- Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility
Hospital administrators must inspect entire building for electrical hazards.
- Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
Access to gas lines must be secured, controlled and randomly tested for content.
- Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
The nurse must measure temperature of all hot liquids before use for any purpose.
- Patient death associated with a fall while being cared for in a healthcare facility
The nurse must perform fall risk assessments and all patient upon admission and daily. Fall prevention protocols must be in place and followed for all those at risk.
- Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility
The nurses must adhere strictly to restraint protocols without exception, including but not limited to range of motion of restrained limbs every hour.
Criminal Events
- Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
Security personnel must check and clear all persons entering the facility.
- Abduction of a patient of any age
All patients must have identifying bracelets that will set off an alarm when passing through an exit without prior clearance.
- Sexual assault on a patient within or on the grounds of a healthcare facility
All hospitals must provide criminal background checks on all employees
- Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility
Any staff member who fails to report a witnessed incident of abuse must become criminally liable for the assault as an accessory.
In conclusion, any health care bill that comes out of congress that does not address these issues of patient safety is as worthless as the politicians who pass it.
Other internet media sources:
Catching up: Casey Cagle on the impact of Democratic health care reform
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