While there are many causes of serious medical errors, from miscommunication among providers to defective medical devices, a leading patient safety organization has cited healthcare leadership’s failure to develop a culture of safety as one of them.
The Joint Commission, which accredits hospitals, publishes a monthly newsletter that focuses on medical errors. Sentinel Event Alert, according to the organization, highlights a specific medical adverse event and examines possible causes. In 2017 one topic was the role of leadership in promoting patient safety. The Joint Commission updated a portion of that newsletter earlier this summer.
The Joint Commission defines a sentinel event as an unexpected “patient safety event that results in death, permanent harm, or severe temporary harm.” They are unexpected as they largely are the result of a preventable medical error.
Medical Errors Third Leading Cause of Death
Medical errors are the third-leading cause of death in the United States, according to Johns Hopkins University School of Medicine researchers (“Medical Errors – The Third Leading Cause of Death in America”). Examples of serious medical errors that can severely harm patients include:
· Surgical errors – wrong site surgery, anesthesia mistakes
· Medication errors – wrong dosage, wrong patient, wrong medicine
· Hospital-acquired infections
· Misdiagnosis – wrong diagnosis, missed diagnosis, delayed diagnosis
Medical errors such as these can be caused by many different factors. One factor, according to the Joint Commission, is a hospital administration’s failure to create and foster a culture of patient safety. It describes a patient safety culture as a combination of how leadership prioritizes patient safety and what it does to keep patients safe.
Failure of Hospital Leadership to Prevent Medical Errors
A failure of leadership to develop a culture of patient safety can take many forms, according to the Joint Commission:
· Insufficient support of patient safety event reporting
· Lack of feedback or response to staff and others who report safety vulnerabilities
· Allowing intimidation of staff who report events
· Refusing to consistently prioritize and implement safety recommendations
So how should hospital leadership help prevent medical errors? The Joint Commission offers several ways that include:
· Encourage reporting of and learning from medical errors
· Establish and communicate to healthcare staff system-wide policies that promote a culture of safety and the reporting of medical errors
· Recognize, not punish, healthcare staff who report unsafe conditions, medical errors or “near misses”
· Utilize safety training, especially in high-risk hospital units such as intensive care, operating rooms, and the emergency department
The Agency for Healthcare Research and Quality is a part of the U.S. Department of Health and Human Services. AHRQ also has addressed leadership’s role and responsibility to prevent serious medical errors. One specific medical error it links to hospital leadership is misdiagnosis.
According to AHRQ, one of every three medical care patients has experienced a diagnostic mistake and nearly 70% of all medical malpractice lawsuits with “high severity” patient injuries involve a misdiagnosis.
AHRQ also reports that diagnostic errors contribute to the death of 80,000 hospital patients in the United States every year.
The agency explains that the diagnostic process often includes many different health professionals, and that those directly involved with a particular misdiagnosis may not be solely to blame. A diagnostic error can also result from a system-process failure.
Investigations of possible negligent medical care should be in-depth and comprehensive to uncover all potential causes, including any potential administration liability.
If you suffered serious harm or you lost a loved one during medical treatment and believe an error may have been made, discuss the details of your case with an experienced medical malpractice attorney.
The choice of a lawyer is an important decision that should not be based solely on advertisements.
Authored by Gray Ritter Graham, posted in Articles September 24, 2021