User:Ashleynlogsdon/Patient safety

In the United States, the public and the medical specialty of anesthesia were shocked in April 1982 by the ABC television program 20/20 entitled The Deep Sleep. Presenting accounts of anesthetic accidents, the producers stated that, every year, 6,000 Americans die or suffer brain damage related to these mishaps. In 1983, the British Royal Society of Medicine and the Harvard Medical School jointly sponsored a symposium on anesthesia deaths and injuries, resulting in an agreement to share statistics and to conduct studies. Copied from Patient safety

Attention was brought to medical errors in 1999 when the Institute of Medicine reported that about 98,000 deaths occur every year due to medical errors made in hospitals. As is the case in other industries, when there is a mistake or error made people look for someone to blame. This may seem natural, but it creates a blame culture where who is more important than why or how. A just culture, also sometimes known as no blame or no fault, seeks to understand the root causes of an incident rather than just who was involved.

When assessing and analyzing an incident, individuals involved are much more likely to be forthcoming with their own mistakes if they know that their job is not at risk. This allows a much more complete and clear picture to be formed of the facts of an event. From there, root cause analysis can occur. There are often multiple causative factors involved in an adverse or near miss event. It is only after all contributing factors have been identified that effective changes can be made that will prevent a similar incident from occurring. Copied from Patient safety

Evidence-based medicine integrates an individual doctor's exam and diagnostic skills for a specific patient, with the best available evidence from medical research. The doctor's expertise includes both diagnostic skills and consideration of individual patient's rights and preferences in making decisions about his or her care. The clinician uses pertinent clinical research on the accuracy of diagnostic tests and the efficacy and safety of therapy, rehabilitation, and prevention to develop an individual plan of care. The development of evidence-based recommendations for specific medical conditions, termed clinical practice guidelines or "best practices", has accelerated in the past few years. In the United States, over 1,700 guidelines (see example image, right) have been developed as a resource for physicians to apply to specific patient presentations. The National Institute for Health and Clinical Excellence (NICE) in the United Kingdom provides detailed "clinical guidance" for both health care professionals and the public about specific medical conditions. National Guideline Agencies from all continents collaborate in the Guidelines International Network, which entertains the largest guideline library worldwide. The International Standard ISO 15189:2007 for Accreditation of Medical Laboratory requires laboratories to continuously monitor and improve the quality of their facilities. Copied from Patient safety

Voluntary disclosure[edit]
In public surveys, a significant majority of those surveyed believe that health care providers should be required to report all serious medical errors publicly. However, reviews of the medical literature show little effect of publicly reported performance data on patient safety or the quality of care. Public reporting on the quality of individual providers or hospitals does not seem to affect selection of hospitals and individual providers. Some studies have shown that reporting performance data stimulates quality improvement activity in hospitals. An article in the New York Times explained that only one in seven errors or accidents are reported, showing that most errors that happen are not reported. Copied from Patient safety


 * Human Factors


 * Variations in healthcare provider training & experience, fatigue, depression and burnout.
 * Diverse patients, unfamiliar settings, time pressures.
 * Failure to acknowledge the prevalence and seriousness of medical errors.
 * Increasing working hours of nurses
 * mislabeling specimen or forgetting to label specimen
 * states of anxiety and stress