A large-scale study that followed mistakes in health care delivery at 10 North Carolina hospitals from 2002 to 2007 found that, despite state efforts, there was no improvement in patient safety over the time period. According to The New York Times‘ Denise Grady, the problem lay primarily not in design, but in execution. Even when safeguards were in place, they were not followed.
The study, published in the New England Journal of Medicine, reviewed thousands of patient records and looked for any of 54 red flags that something had gone wrong.
Dr. [Christopher] Landrigan’s team focused on North Carolina because its hospitals, compared with those in most states, have been more involved in programs to improve patient safety.
But instead of improvements, the researchers found a high rate of problems. About 18 percent of patients were harmed by medical care, some more than once, and 63.1 percent of the injuries were judged to be preventable. Most of the problems were temporary and treatable, but some were serious, and a few — 2.4 percent — caused or contributed to a patient’s death, the study found.
The findings were a disappointment but not a surprise, Dr. Landrigan said. Many of the problems were caused by the hospitals’ failure to use measures that had been proved to avert mistakes and to prevent infections from devices like urinary catheters, ventilators and lines inserted into veins and arteries.
Problems cited in the study include a lack of electronic medical records, doctors and nurses regularly working long hours and poor compliance with even simple interventions such as hand washing. Proposed solutions include computerized drug ordering systems and a mandatory nationwide monitoring system.
