Medical Mistakes
Continued from page 152
of the WHO’s 19-item Surgical Safety Checklist
in eight hospitals in eight countries representing
a variety of economic circumstances. 15 Adherence
to these checklists decreased the rates of adverse
events, surgical mortality, surgical-site infection, and
unplanned reoperation, compared with the period
before the checklists were implemented.
Despite its ability to improve outcomes, the
WHO checklist is only a partial solution, albeit one
that is widely used in operating rooms across the
world. Making a dent in preventable medical errors
will require successful implementation of safety
checklists at a large scale and buy-in from all stake-
holders, including hospital CEOs. 16
Practice guidelines and protocols are another
way to reduce practice variation and prevent errors.
In addition to aiding memory, they also serve to set
performance standards and expectations for health-
care professionals.
“We have not
come up with
reliable systems for
communicating
key data across
institutions, and I
think it’s possible
that this can put
patients at risk.”
—JOSEPH JACOBSON, MD, MSc
ASH’s Committee on Quality is focused on develop-
ing evidence-based practice guidelines for several areas
of hematology practice. ASH just released the first six
of 10 clinical practice guidelines on venous throm-
boembolism in late November, and future efforts will
cover immune thrombocytopenia, sickle cell disease,
leukemia in older patients, and von Willebrand disease.
Reducing excessive resource use, experts contend, re-
duces the opportunity for preventable medical mistakes,
like medication errors or unnecessary transfusions.
“On the Committee on Quality, we are trying to
develop evidence-based guidelines, which is one way
to try to disseminate best practices, decrease practice
variation, and ultimately improve safety by ensuring
that there’s high-quality guidance available for physi-
cians,” she told ASH Clinical News.
Dr. Hicks also chairs the Choosing Wisely
Task Force for ASH. Choosing Wisely is a medical
stewardship initiative led by the American Board
of Internal Medicine Foundation in collaboration
with U.S. professional medical societies. In 2013 and
2014, Dr. Hicks and her team identified 10 hema-
tologic tests and treatments that hematologists and
their patients should question ( SIDEBAR 2 ). 17,18
“When we start to view things through the lens
of overuse, we’ll find examples in every field, just like
there are examples of medical error in every field,”
she said.
154
ASH Clinical News
A New Era of Patient Safety
“To err is human, but errors can be prevented,” wrote
the authors of the IOM report in 1999. In the almost
20 years since publication of this transformative report,
progress – albeit variable and inconsistent – has been
made to do just that, authors wrote in an editorial
summarizing the past two decades of the patient safety
movement. 19 New approaches are needed to address
both prior and emerging areas of risk. The next chal-
lenge will likely by to find tools that allow organizations
to “measure any reduction of harm both inside and
outside the hospital, continuously and routinely.”
If the time since the IOM report might be
considered the Bronze Age of patient safety, when
“primitive” tools were developed to begin measuring
and managing patient error, the next decade prom-
ises to be the Golden Age, where “vast improvement
in patient safety” is realized, they concluded.
—By Debra L. Beck ●
REFERENCES
1.
SIDEBAR 2
American Society of Hematology presents
TEN THINGS PHYSICIANS AND
PATIENTS SHOULD QUESTION
1 Don’t transfuse more than the minimum
number of red blood cell (RBC) units necessary
to relieve symptoms of anemia or to return a
patient to a safe hemoglobin range (7 to 8 g/dL
in stable, non-cardiac in-patients).
2 Don’t test for thrombophilia in adult
patients with venous thromboembolism
(VTE) occurring in the setting of major
transient risk factors (surgery, trauma or
prolonged immobility).
3 Don’t use inferior vena cava (IVC) filters
routinely in patients with acute VTE.
4 Don’t administer plasma or prothrombin
complex concentrates for non-emergent
reversal of vitamin K antagonists (i.e. outside
of the setting of major bleeding, intracranial
hemorrhage or anticipated emergent surgery).
5 Limit surveillance computed tomography
(CT) scans in asymptomatic patients
following curative-intent treatment for
aggressive lymphoma.
6 Don’t treat with an anticoagulant for more
than three months in a patient with a first
venous thromboembolism (VTE) occurring in
the setting of a major transient risk factor.
7 Don’t routinely transfuse patients with
sickle cell disease (SCD) for chronic anemia
or uncomplicated pain crisis without an
appropriate clinical indication.
8 Don’t perform baseline or routine
surveillance computed tomography (CT)
scans in patients with asymptomatic, early-
stage chronic lymphocytic leukemia (CLL).
9 Don’t test or treat for suspected heparin-
induced thrombocytopenia (HIT) in patients
with a low pre-test probability of HIT.
HHS.gov. Opioid crisis statistics. Accessed October 29, 2018, from
https://www.hhs.gov/opioids/about-the-epidemic/index.html.
2. Makary MA, Daniel M. Medical error—the third leading cause of
death in the US. BMJ. 2016;353:i2139.
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building a safer health system. Washington (DC): National
Academies Press (US); 2000.
4. James JT. A new, evidence-based estimate of patient harms
associated with hospital care. J Patient Saf. 2013;9:122-8.
5. Gilligan T. Trespass and forgiveness. Cura. Accessed November
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forgiveness/.
6. Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of
medical errors on practicing physicians in the United States and
Canada. Jt Comm J Qual Patient Saf. 2007;33:467-76.
7.
Collaborative for Accountability and Improvement. Communication
& resolution programs. Accessed October 29, 2018, from http://
communicationandresolution.org/communication-and-resolution-
programs/.
8. Gallagher TH, Mello MM, Sage WM, et al. Can communication-and-
resolution programs achieve their potential? Five key questions.
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9. Kachalia A, Sands K, Van Niel M, et al. Effects of a communication-
and-resolution program on hospitals’ malpractice claims and costs.
Health Aff (Millwood). 2018;37:1836-44.
10. AHRQ. Communication and Optimal Resolution (CANDOR)
Toolkit. Accessed October 29, 2018, from https://www.ahrq.gov/
professionals/quality-patient-safety/patient-safety-resources/
resources/candor/introduction.html.
11. Dossett LA, Kauffmann RM, Lee JS, et al. Specialist physicians’
attitudes and practice patterns regarding disclosure of pre-referral
medical errors. Ann Surg. 2018;267:1077-83.
12. Dossett LA, Kauffmann RM, Miller J, et al. The challenges of
providing feedback to referring physicians after discovering their
medical errors. J Surg Res. 2018;232:209-16.
13. Ratwani RM, Savage E, Will A, et al. Identifying electronic health
record usability and safety challenges in pediatric settings. Health
Aff (Millwood). 2018;37:1752-9.
14. Classen D, Li M, Miller S, Ladner D. An electronic health record-based
real-time analytics program for patient safety surveillance and
improvement. Health Aff (Millwood). 2018;37:1805-12.
15. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to
reduce morbidity and mortality in a global population. N Engl J Med.
2009;360:491-9.
16. Berry WR, Edmondson L, Gibbons LR, et al. Scaling safety: the
South Carolina surgical safety checklist experience. Health Aff
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campaign: five hematologic tests and treatments to question.
Blood. 2013; 122:3879-83.
18. Hicks LK, Bering H, Carson KR, et al. Five hematologic tests and
treatments to question. Blood. 2014;124:3524-8.
19. Bates DW, Singh H. Two decades since To Err is Human: An
assessment of progress and emerging priorities in patients Safety.
Health Aff (Millwood). 2018;37:1736-43.
10
Don’t treat patients with immune thrombo-
cytopenic purpura (ITP) in the absence of
bleeding or a very low platelet count.
December 2018