My coworker shared with me her daughter’s scary experience of a clinic visit, which involved a potential medical error. Her daughter almost received two identical shots during the same visit by two different nurses. At the beginning of the visit, the nurse gave her daughter a shot without informing her the name of the medication and the reason for getting this medication.  Unfortunately, her daughter did not ask about it, either. After the shot, the nurse forgot to log this information in the computer. Then, her daughter went to the laboratory to get her blood drawn. Another nurse saw the computer screen, which showed the medication was overdue.  This second nurse was planning on giving her another shot of the same medication given to her earlier.  Fortunately, my co-work asked about the medication and found it was the same one.  A potential medical error was therefore averted.  Had her daughter received the same shot twice, the excess amount of medication would cause her arm to swell up and it would take days to recover.

This kind of medical error is not un-common in many different medical practices.   The Institute of Medicine (IOM), which is part of the National Academy Sciences, estimated that medical errors in American hospitals contributed to as many as 44,000 to 98,000 death. Although these errors are most likely systematic problems rather than poor performance of individuals, the adverse events cost the nation $37.6 billion dollars each year.  $17 billion of those errors could have been prevented.  Examples of preventable errors include errors in prescription, or in administering, of medication, or allergic reaction to medication. Therefore, it is very important to promote the best practice to prevent this type medical malpractice. This is not only the responsibilities of health care professionals and administers of healthy care agencies, but also the responsibilities of patient and patients’ families. The right of subsistence should be protected since the moment we came to this world. Everyone needs to demonstrate his or her respect of human’s lives.

A patient should

1. clarify with doctors or any healthy care professionals on medical terminology or information that is unclear to them,  and
2. check with nurses or doctors before any medication/procedure given, and also the reason for getting these treatments.

Health care professionals

1. are responsible for ensuring the safety of your patients, and should
2. treat the patients as family members and exercise extra care,
3. should explain the procedure or medication before starting any treatments,
4. should discuss with patients and/or patients’ family members the benefits and risks before treatments.

Administers of health agencies should

1. continue to develop, test, and implement new programs that will ensure patient safety, including medication safety, infection prevention, and reduction of surgical complications; For example, lot s of medical errors were due to unclear labeling on drugs. Thus, it is important to improve drug-labeling system to avoid the errors.
2. continue to provide educations to patients and health care professionals and focus on patients’ rights and safety issues.
3. prevent overtime and extended work hours. Extended work hours and shift work have been proven to increase staff fatigue, health care errors, adverse events and outcomes, and decrease alertness and productivity.

As a health care professional, I hereby appeal to everyone to start from ourselves to respect human rights, to avoid preventable medical errors, and to promote patient safety.

References:

1. U.S. Department of Health & Human Services