On the morning of the last day of treatment, pharmaceutical technicians prepared an iv bag with a dose 20 times higher than the recommended amount of sodium chloride. A few hours later, Emily supported and declared her brain dead.
Three days later, she left.
Sadly, Emily’s case is not unique. More than a quarter of a million americans die each year from medical errors, making it the third leading cause of death after heart disease and cancer, according to a recent study from Johns Hopkins university.
Other studies have reported higher Numbers, claiming 440,000 people have died from medical errors. The reason for the discrepancy is that doctors, funeral directors, coroner’s officers and medical inspectors rarely identify human error or system failure on death certificates. However, death certificates are the basis for the centers for disease control and prevention to rely on a nationwide statistical distribution of deaths.
The authors of the Johns Hopkins study, led by Dr. James Makary of Johns Hopkins university school of medicine, called on the CDC to change the way it collects data from death certificates. So far, Makary says, nothing has changed.
‘the system is to blame.’
Dr. Makary defines medical errors as unskilled employees, judgment or nursing errors, system defects or preventable adverse reactions. These include computer glitches, confusion with the dosage or type of medication given to the patient, and undiagnosed surgical complications.
“At present, the centers for disease control and prevention, the use of death collection system, the system can only record the disease and pathology, and hurt the cause of death,” marca Dr In a letter urging the centers for disease control and prevention, to change the important way of collection for health statistics.
“The system is not just a personal responsibility,” Dr. Makary said. The U.S. patient care study, released in 2016, has been exploring mortality data for eight years. The researchers found that 251,454 people die each year, or 9.5 percent of all deaths, because of medical errors that lead to 35,416,020 hospitalizations.
“Health care workers are warm, caring people, but they are human and human beings who make mistakes,” he said. According to him, Emily gave lethal doses, the hospital pharmacy was understaffed, the pharmacy’s computers were not working properly and doctors were overstocked.
Chris later said he had found a pharmacy technician, not a trained and trained pharmacist, who made nearly all the iv drugs for patients. Many states do not require or have the ability to prove these pharmaceutical technicians.
In order to seek better patient protection, Chris was founded in 2008 the Emily. Jerry foundation EJF better focus on drug safety and technical personnel training, as well as the improvement of health care system backup programs. Last year, he announced the Emily jerry foundation’s national pharmacy technician program, an interactive scorecard to inform the public about America’s unsafe pharmacy practices. He also traveled across the country, telling stories about patient safety and proving the best way to minimize the “human error” component of medicine.
Any new tool ‘will change the rules of the game’
Pascal Metrics, based in Washington, dc, has devised a way to improve patient safety and clinical reliability in health facilities.
Dr. David Klarson, PASCAL’s chief medical information officer, is an associate professor of medicine at the university of Utah and an infectious disease consultant at the Utah school of medicine in Salt Lake City. He acknowledges the problem: “the nursing system is decentralized,” he says. “Any tool that allows patients to manage their healthcare needs will change the game.”
To improve the safety of drug use, Dr. Classen developed and implemented computerized order entry programs at LDS hospital in Salt Lake City. “It is important to use health information technology by using electronic health records in hospital and outpatient Settings,” he said.
As far as hospitals are concerned, many hospitals are struggling to keep up with more and more technologies to improve patient safety. Kim Lanyon, a senior nurse at the ICU’s danbury hospital in Connecticut, said all electronic records had been double-checked and security equipment was in place. ”
At mount sinai hospital in New York City, Dr. Vicki LoPatchin oversaw the Good Catch award, which was awarded to medical staff to identify potential or existing errors related to patient care. Also, most doctors’ offices now store records electronically and record conversations between doctors, nurses and patients to make sure they are clear and correct.
Even so, Makary says there are common complications, especially unnecessary medical care. “Twenty percent of all medical procedures may not be necessary,” he said. He also opposed excessive use of postoperative drugs, especially opioids.
As the website Dollars for Docs shows
He says doctors are encouraged by pharmaceutical companies and sometimes “sell” their products in cash.