Analyzing medical errors helping hospitals prevent future mistakes
At the University of Kentucky Healthcare’s A.B. Chandler Medical Center, it’s Paula Holbrook’s job as the director of risk management and clinical risk to capture all of the “near misses, the little things that don’t reach the patient” and turn it into a learning experience for the hospital and staff on how to prevent such occurrences from happening in the future.
By collecting reports from hospitals and staff, Holbrook and her team have the opportunity to intervene early and prevent hazards from becoming losses. “You want to get this before you have that ‘Oh my God’ moment,” she explains.
Medical mistakes can occur in hospitals across the state of Kentucky and can be as harmless as taking the wrong patient to surgery and realizing the mistake before the operation takes place, or more serious errors that can result in injury or wrongful death. Mistakes like this can lead to serious medical malpractice suits which can leave lasting negative impressions.
In an effort to stop future accidents from happening, the Agency for Healthcare Research and Quality developed Common Formats, an electronic tool that helps risk-management staff identify failure points in communication and processes in order to correct the error from happening again. It’s currently being used in multiple hospitals across the state, and now after six years of development, will now allow hospitals to report problematic systems or conditions to other hospitals so that they may learn from these mistakes.
As some critics have pointed out, the system isn’t perfect and sometimes there are different variables that can cause medical mistakes. It’s important for patients to remember that despite all of the safe guards, accidents in hospitals can still happen and when it does, seeking knowledgeable representation will be key to receiving compensation in legal disputes.
Source: Health Leaders Media, “The Near Miss,” Cheryl Clark, Dec. 13, 2012