Hospitals take simple steps to prevent harm

Dan Gorenstein Nov 1, 2012

Hospitals take simple steps to prevent harm

Dan Gorenstein Nov 1, 2012

When you go to the hospital, you expect to get better, right? But actually hundreds of thousands of people get worse: infections, pneumonia, sometimes a patient falls and breaks a hip.

Hospitals have come to realize lots of these problems are preventable. While that’s good for patients, it can be great for a hospital’s bottom line.

Nobody knows exactly how many people in the U.S. die from the mistakes hospitals make. But Peter Pronovost at Johns Hopkins Institute for Patient Safety says what we do know is pretty scary.

“100,000 people die from infections that hospitals or healthcare organizations give them,” he says. “100,000 die from blood clots. 80,000 to 100,000 die from misdiagnosis.”

Pronovost says not all of those deaths are preventable, but most are. And there’s the thousands who die from miscommunication errors and the treatment mistakes.

“You add all those up,” says Pronovost. “You end up with the third leading cause of death.”

Pronovost says only cancer and heart disease kill more Americans every year than what’s known as preventable harm — basically errors that could be avoided.

Former Hospital CEO Paul Levy, a patient safety expert, says hospital staff must look in the mirror.

“The problem we have in medicine is that its viewed as a craft in which each doctor does each thing in his or her own way,” he says.

Levy says to really tackle the problem, doctors and nurses need systems — kind of like airplane pilots.

“We expect the pilot to follow without variation, a certain checklist for doing the standardized things that need to be done. For much of medicine we need to do the same thing,” says Levy.

In the past two years, Holy Redeemer Hospital in suburban Philadelphia has begun holding a daily check-in safety call every morning. And the hospital — like lots of hospitals around the country — has made real progress in reducing infection rates thanks to new national protocols.

But figuring out most protocols is not easy. Take patient falls.

Holy Redeemer has tried a little bit of everything — non-slip socks, lowering bed heights, alarms that go off when a patient gets up…and Andrew Zindell.

“The gentleman I am sitting with him today, every time he tries to get up, I think about worrying about him trying to get up and fall,” says Zindell.

That’s right — in the 21st Century sometimes the best way to make sure someone doesn’t fall is to pay a nurse’s aide like Zindell to just sit there.

While developing new standards obviously takes time and money, hospital executives have found when there are standards to plug in it’s worth it. Dr. Ken Sands says his hospital — Beth Israel Deaconess Medical Center in Boston — had drawn up blueprints for a new intensive care unit. At the same time, the hospital began new protocols on ventilators, like raising patients up and brushing their teeth, and cases of related-pneumonia fell by 2000.

Sands says the hospital could scrap plans to build the new ICU.

 “We were able to save the institution tens of millions of dollars,” he says.

Hospitals are under growing pressure to eliminate preventable errors. If they don’t, insurers and the federal government will make hospitals pay for it. Health care executives agree saving money alone won’t inspire doctors and nurses to do the hard work to improve patient safety.

Holy Redeemer’s Chief Safety Officer Karen Renson says management must remind staff why they are there to help, not harm. Renson herself gave a patient the wrong medicine 30 years ago.

“I’ll never forget the way it makes you feel. You want to die, the whole bottom of your stomach falls out. You feel like I’m not going to be a nurse anymore. I’m giving this up. I gotta figure out something else I want to do,” says Renson.

She says the reality is that as long as human beings are working on other human beings mistakes will be made.

But Renson says that doesn’t mean there’s no point in trying.

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