Deaths caused by preventable medical errors are unnervingly commonplace in modern American healthcare, but our health system still hasn’t stumbled upon a solution. Addressing issues with staff communication is a superficial issue, and as much as it makes sense to us logically, patient-provider relationships aren’t at fault here either. It’s easy to blame the nurse’s disrespectful bedside manner or the doctor’s arrogant demeanor, but its essential to remember that the vast majority of healthcare providers aren’t denying patients the care they need for some arbitrary reason. Professionals just aren’t that catty in potentially fatal situations.
What we’ve just mentioned are just symptoms of the underlying issue — so let’s stop scratching at the surface and dig deeper. If we want to eliminate medical error fatalities for good we need to get to the core of the problem. Here’s where Amplefi comes in. We have been studying the inner workings of hospitals for 15 years and we’ve learned a lot along the way. We’re good at identifying true causes and bypassing superficial symptoms, and we’re about to share some of our discoveries with you in this post.
So here it is, the four factors behind fatal medical errors:
To illustrate this properly, lets create a fictional nurse. We’ll call her Mary. Now let’s give Mary a fictional patient, Jay. Jay is in very serious condition; he has suffered a complication from surgery and has an infection that’s quickly spreading. He has orders for a very strong antibiotic. He must be given this antibiotic at extremely specific time intervals or the bacteria will become resistant to it and cause sepsis, a potentially fatal condition. Nurse Mary forgot to give Jay his meds at the correct time, and he went septic overnight. How did it happen? How could Mary forget to do such a simple task? Let’s find out.
Nurse Mary works on a nursing floor of her fictional hospital and she has 6 patients. For each of these patients, she must give them medication, help them with personal hygiene, take vitals, respond to emergencies. . . The list could go on and on. Do you get what I’m saying? Jay is just one of 6 ill patients, to her he can’t be special, and she cannot give him her undivided attention. The majority of Americans can’t afford their personal private nurse, that’s why we go to the hospital in the first place. Because these healthcare providers are a shared commodity, multi-tasking is inherent in their work day.
2. Time Pressure
Nurse Mary has a lot to do, so much in fact that she can barely find enough time to use the bathroom or eat her lunch. She is on her feet all day tending to the ins and outs of caring for her patients. A lot of these patients are due for medications at the same time, and some of these medications (like Jay’s) are time sensitive. She also has to find time to help the patients with their hygiene, and make sure they’ve eaten. Truth is, she can’t afford to slow down to double check what tasks she has completed. That makes it easier for things to fall through the cracks.
3. Reliance on Memory
Since Mary is multi-tasking under extreme time pressure, the last thing she is going to do is give herself the additional task of creating a hard copy check-list to mark off what she has completed. Reality is, she has this check-list in her brain, and since her brain doesn’t work like a computer, she forgets things.
Let’s give Mary the benefit of the doubt and say she has remembered to give Jay his meds at the right time. That is, until, one of Mary’s other patients goes into cardiac arrest. Mary has to totally drop what she is doing to go deal with this other catastrophe. Because she was multi- tasking and relying on her memory while under time pressure, she has forgotten to give Jay his medication. The next day, Jay went septic and is sent to the ICU, struggling for his life.
That’s how quickly it can happen. Notice how all four of these factors combined to form the fatal outcome. That’s because these four factors are ever present in our healthcare system and we cannot eliminate them. Furthermore, as patients we want these factors to be in play at least some of the time. Let’s take Interruptions for an example. Think about it: your nurse is preparing to perform a routine blood draw on another patient, when you start having a heart attack. Wouldn’t you want her to drop what she’s doing and tend to you first? Of course you would. The key point here is that fatal error only happens when all of these factors occur at the same time. So how can we keep these factors from combining? The answer to that question will drastically reduce medical errors in your operation.