– “Doctor…Can’t take this s*** anymore…I am heading for the exit door—You should do the same.”
Sheila X. is a proficient Critical Care nurse that, after a medical error she committed in a medication schedule that was providentially spotted by her supervisor, decided that her work stress was too much, especially after toiling so hard in the pandemic. She could opt for an early retirement, with a nice monthly check and benefits; she did not want to risk those benefits for the sake of a few more months of work. It was time for her to quit a career she has always loved. She stopped being sentimental like so many of us still are.
In a 1999 Institute of Medicine’s publication titled To Err is Human, Building a Safer Health System, investigators found an alarming rate of medical errors in the USA, which could be at least 44.000 incidents per year, even reaching the astounding number of up to 98.000 deaths of admitted patients in hospitals and clinics. We must assume that for each incident, there might be at least one, two, three, even more nurses, technicians and physicians involved, with varying degrees of responsibility. Medical Errors could represent the third leading cause of deaths in the USA.
Note. This World War II US Navy’s recruiting poster was taken form Wikimedia Commons. At that time Women were not allowed to serve in any frontline combat positions and had to staff the auxiliary sections of the Marine Corps. That sounds so, so retrogradely condescending now. As the famous Virginia Slims poster said; “You’ve come a long way Baby.”
The IOM Committee on Quality of Healthcare in the USA stated that a Medical Error is “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.” We must clarify that a priori a medical error does not imply that there has been an intentional act to commit harm to a patient or an act of medical malpractice. There are two major types of Medical Errors defined as follows:
- Error of Execution: the planned action does not proceed as it was intended.
- Error of Planning: the originally intended action was poorly designed.
Not all medical errors reach the grave status of a “sentinel incident” that must be reported to the hospital authorities and the regulating agencies for professionals. If there is a common complication like a wound infection after a major procedure, professionals must evaluate whether it was totally preventable if a mistake would not have been committed, or it was simply a complication that could not be avoided.
The Joint Committee, a national organization charged with studying Medical Errors, defined a sentinel event as “an unexpected occurrence involving the death of or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function.” They proposed using the root case analysis to identify “the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event.”
There are two major types of sentinel events as follows:
I – Death of the patient or a serious permanent loss of function, not associated with the expected clinical course of the pathological condition or co-morbidity.
II – It involves one or two of the following medical conditions, which do not attain the seriousness of death or loss of a major bodily functions. They are:
- Suicide of an admitted patient.
- Unexpected death of a full-term infant.
- Abduction of an admitted patient.
- Assignment of the wrong infant to a family.
- Rape, battery, or assault of an admitted patient.
- Rape, battery, or assault of a Staff member.
- Administration of incompatible blood products.
- Post-operative retention of a Foreign Object.
- Severe Neonatal Hyperbilirubinemia.
- Prolonged Fluoroscopy with Excessive Radiation dosage.
- Maternal morbidity or mortality.
- Fire hazard.
In a series of articles, we will discuss the major types of Medical Errors and how they profoundly affect the treating personnel, not only because they might have been involved in such an instance, but also because they might be genuinely concerned that it might occur to them. Only well trained and hypervigilant professionals avoid the risk of any of them.
Stay distant. Stay safe. Stay beautiful.
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Don’t leave me alone.