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Study looks at errors in labeling specimens
Risk managers know that communication errors often are a root cause of sentinel events in surgery, and a new study is reporting that specimen labeling is a common error that can threaten patient safety.1
In a six-month study of 21,351 surgical specimens, researchers from Johns Hopkins University School of Medicine in Baltimore found 91 labeling errors, for an annual rate of 182 errors. The five most common types of errors were specimen not labeled (18), empty specimen container (18), incorrect laterality (16), incorrect tissue site (14), and incorrect patient (11).
Breast procedures were the most common type of surgery to have an error. Nearly 60% of errors were associated with a biopsy procedure.
1. Makary MA, Epstein J, Pronovost PJ, et al. Surgical specimen identification errors: A new measure of quality in surgical care. Surgery 2007; 141:450-455.
Patient safety incidents up, big gap with best and worst
Patient safety incidents at the nation's hospitals rose over the years 2003 to 2005, but the nation's top-performing hospitals had a 40% lower rate of medical errors when compared with the poorest-performing hospitals, according to the results of a recent study.
The data come from the largest annual study of patient safety, conducted by HealthGrades, an independent health care ratings company in Golden, CO. The HealthGrades study of 40.56 million Medicare hospitalization records over the years 2003-2005 found that patient safety incidents continue to rise in American hospitals, with 1.16 million preventable patient safety incidents occurring over the three years studied among Medicare patients in the nation's hospitals, an incidence rate of 2.86%. The excess cost to hospitals was $8.6 billion over three years, with some of the most common incidents proving to be the most costly.
Patient safety incidents with the greatest increase in incident rates were postoperative sepsis (34.28%), postoperative respiratory failure (18.7%) and selected infections due to medical care (12.23%). Patient safety incidents with the highest incidence rates were decubitus ulcer, failure to rescue, and postoperative respiratory failure.
The top performers
Of the nearly 5,000 hospitals studied, the HealthGrades study identified 242 hospitals in the top 5% of all hospitals, says Samantha Collier, MD, HealthGrades' chief medical officer and the primary author of the study. Those hospitals — named Distinguished Hospitals for Patient Safety — were used as a benchmark against which other hospital efforts regarding patient safety could be evaluated.
On average, these hospitals had a 40% lower rate of patient safety incidents when compared with the poorest-performing hospitals, Collier says. If all hospitals performed at the level of the Distinguished Hospitals for Patient Safety, the study found that approximately 206,286 patient-safety incidents could have been avoided, 34,393 Medicare deaths could have been avoided, and $1.74 billion could have been saved.
"Despite the flurry of research, publications and process improvement activity that has occurred since the [Institute of Medicine] report there is a growing consensus that not much progress has been made leading to a visible national impact," the study says. "Our findings support this consensus. However, our findings also support that progress continues to be made at the top."
So what separates the best from the rest? The HealthGrades report says that "Distinguished Hospitals have deliberately chosen and maintained patient safety as a top priority."
For the full report, go to the company's web site at www.healthgrades.com. Under the subhead "HealthGrades Research," see "patient safety study."