Simple Checklists and Error Proofing Can Help Hospitals Save Lives

Posted by on Mar 21, 2012 in Continuous Improvement, Lean Six Sigma | 0 comments

We’ve all heard stories where surgeons have operated on the wrong person or body part.  But you might not know that this happens much more frequently than you suspect.  An article by Katharine Greider, in the AARP Bulletin March edition, states that this happens as often as 40 times a week.  Some other startling facts include:

  • Each year as many as 100,000 Americans die in hospitals from preventable medical mistakes.
  • In a study in the journal Health Affairs, published last spring, researchers examined patients charts at three US leading hospitals and found that an astounding one in three admissions included some type of harm to the patient.
  • The number of patients who die each year from preventable hospital errors is equal to four full jumbo jets crashing each week.

Mistakes run the gamut.  Surgeons can nick a healthy blood vessel; a nurse can mistakenly administer a toxic dose of medication or the wrong medication; staff can fail to adequately disinfect a room, and a patient can contract a dangerous infection.

Today there are 13,600 diagnoses, 6,000 drugs, 4,000 medical and surgical procedures.  As one Harvard associate professor and surgeon stated, “At it deepest level, what we’re now having trouble with is the enormous complexity of medicine.”

One reason medical errors continue as such high levels is that hospitals have only recently begun to use aviation’s simple use of a checklist to account for human fallibility.  Around the country, safety innovators have introduced promising ways to minimize errors — from using checklists to reporting hospital infection rates on websites.  In a 2004 program launched in Michigan, more than 100 intensive care units managed to reduce infections by two-thirds, and save some 1500 lives in just 18 months, just by using a short checklist of practices for handling catheters, and a culture change in getting all staff on board.

Checklists and error proofing, if used correctly, are great tools to help reduce human error.  They have the ability to stop mistakes before they occur or make a mistake obvious at a glance.  Hospital administrators and physicians need to make sure their staffs are trained and understand the importance of using these simple tools to prevent errors and save lives.

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