The real challenge is not to document how bad it has been, but instead to focus on how to help those who are actually providing care to patients. This task is more difficult but also more important, and likely to be what we will need to improve care.
Among the many misconceptions that people have about medical errors, particularly in diabetes care, is the belief that there is always someone to be held accountable for the error and that the focus should be disciplining and ultimately removing the person who made the error from the system.
In truth, most of the important medical errors are multifactorial in nature and are the result of numerous small oversights, any one of which, if corrected, might have prevented or reversed the error. At least half of the errors are probably contributed to by a faulty system of care, which often is the main culprit. An example: a hospitalized patient has hypoglycemia and then develops chest pain, but the hospital is losing money and has cut nursing coverage. The non-nurse technician assigned to the patient does not have the nursing skill to understand that the patient's chest pain is not caused by low blood glucose and so ignores the chest pain, treats the low glucose, and leaves. The patient dies from the initially ignored heart attack.
In this example, the "system" is providing obstacles that result in blame falling on the individual at the point of care. But these problems really have more to do with the system of care itself, situations in which there is a defective "culture of safety." A culture of safety can be defined as any clinical entity working as a cohesive unit on behalf of patients' safety.
Another very important misconception is the belief that correcting all errors is the main task. Not so. Most errors are not harmful to anyone and are usually spotted by the very people who make them. We all know this category well. These are primarily the slips and lapses that we have made or the omissions of steps by making shortcuts. For the most part, we usually correct these types of errors when we review our work. Many of us are under considerable stress in our clinical settings. Because people under stress are more prone to error, it makes sense to be sure that our systems of care allow us enough time to check our own work. Also, it is sound strategy to set up other procedures to routinely check both our work and others. In this way, the vast majority of errors can be caught and corrected without harming patients.
Clearly, the best strategy for preventing errors that cause harm is not to focus on whom to hold accountable for the harm. Instead, we need to provide a system of care in which patients are well protected from even the few accidental errors that we are unable to prevent with our new strategies of error reduction.
Many errors are repeated over and over again because they are not reported and shared with others. One of the ways we can prevent similar errors, is to report them to the organization www.ismp.org. You can do this online without identifying yourself. They will then publish the error to hundreds of thousands of medical professionals. By sharing our errors we can prevent other medical professionals from making the same mistakes.
A central problem is the need to improve the ways in which we currently handle medical information. We need new methods to document important clinical information and to make the transfer of information as clear and unambiguous as possible. In most hospital settings, both electronic medical records (EMRs) and hospital electronic medication ordering play an increasingly important role. The rationale for these changes is that, under our current systems, many medication errors are simply the result of misinterpretation of prescriptions or orders, misreadings that often have catastrophic consequences.
Although EMR can prevent errors like the poor quality of handwriting, preventing errors of similar names and doses, it also opens the door for new types of errors such as checking off the wrong dose, directions, or even the wrong drug.
We should now routinely run a drug-interaction check on prescriptions before giving them to patients. This is an additional check on safety that can be done instantly with an EMR system.
Nursing ratios should be higher when patients with diabetes are hospitalized. Frequent glucose monitoring, wound care, and the clinical needs of those with orthostatic hypotension, renal disease, and retinopathy can lead to increased nursing requirements. We can do a great deal to champion the need for more nurses at the bedsides of our patients and for access to diabetes educators for our inpatients who require instruction.
When trying to make a safer environment for patients, we must also consider the most common and best known source of errors in diabetes care: patients. Much of our traditional emphasis on patient and family diabetes education is a result of our recognition that our therapy should be patient-centered. We have long understood that the greatest burden is on the patients themselves.
But our methods of education do not always take into account the myriad ways even intelligent and interested patients can misinterpret well-meaning providers' educational efforts. Also, we must remember that patients can forget or distort what they have learned. We must constantly check and probe to clarify what people may have learned at one time but then forgotten. Often, patients' errors in self-care can be traced to their misconceptions or their misunderstanding of the process of self-care. This can lead to catastrophic error on their part. Example: one of the major errors in using an insulin pen is when the patient sticks themselves with the insulin pen and dials up the dose, but then rather than pushing on the plunger to inject the insulin dose, they dial back the dosage to zero, without ever injecting themselves. Of all of the difficulties we have in patient care, the challenge of helping patients re-clarify what may have been once clear to them is perhaps the most difficult and also perhaps the most important. Years of experience have shown us that one of the best ways to prevent errors is by educating your patients.
But if we are to improve safety for our diabetic patients, where do we need to place our efforts? As a start, we can:
- offer more education that is patient-centered, allowing the patients to demonstrate what they know;
- increase awareness of the need for adequate resources, particularly sufficient time for providers to thoroughly evaluate clinical problems;
- form ad-hoc teams of doctors and nurses to work together more cohesively in the care of diabetic patients;
- change the paradigm so that providers think less about who is to blame and more about how to prevent catastrophes caused by the system in which they work;
- change the tort system so that hospitals and providers can focus on making the system better and not on avoiding frivolous and illogical lawsuits; and
- make our system of care as focused on quality as it is on cost containment.
Each of these issues will play an important role in the improvement of our system of care and in the protection of our diabetic patients from the consequences of medical errors.
As Yogi Berra said: "When you come to a fork in the road, take it!"
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