O C T O B E R 2 0 1 6 O U T P A T I E N TS U R G E R Y. N E T 7
Problems persist
Medical errors are the third leading cause of death in the United States, behind
only heart disease and cancer, according to a recent study in The BMJ (see "It's
Time for Honest Discussions About Medical Care Gone Wrong" on p. 40 for
insights from the study's author). Certain aspects of heart disease and cancer
remain a mystery, but that's not the case with medical errors. We already know
how to prevent them, and doing so doesn't require singular acts of heroism. It
simply requires leadership, accountability and a culture of safety. Healthcare
economics and clinical advances are shifting more surgeries into the outpatient
arena. The rise in both the number and complexity of outpatient procedures
increases the potential for life-threatening mistakes and puts facilities like yours
on the front line in the battle against medical errors.
Unfortunately, patients are continually put in jeopardy. In 2010, for example,
CMS piloted an infection control audit tool in 70 ASCs throughout 3 states to
assess practices related to hand hygiene, injection safety, medication handling,
environmental cleaning, equipment sterilization and disinfection, and the han-
dling of blood glucose equipment. The findings? More than two-thirds of the
ASCs had at least a single infection control oversight, and about one-fifth had
more than 3 lapses. That's alarming, especially when you consider ASCs often
outperform hospitals when it comes to following infection control guidelines.
Wrong-site, wrong-procedure and even wrong-patient surgeries — appropri-
ately (or ironically) called "never" events — are perhaps the lowest hanging
fruit in addressing the medical error crisis. However, an estimated 1,300 to 2,700
"never" events occur each year in the United States (including inpatient and out-
patient settings), according to a 2006 study published in JAMA Surgery that
examined mandatory and voluntary reporting systems. The authors attributed
many of these mistakes to communication breakdowns and a lack of adequate
safety systems. These are glaring, preventable errors that continue to occur for
no good reason.
