10 медицинских ошибок, которые изменили стандарты мед.помощи. Часть II

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Tom was 12 years old when his appendix burst and he was taken to the local pediatric hospital. Three days after the appendectomy, he developed another high fever. One week later, the surgeon performed a second procedure and found that a surgical sponge had been left inside. 

Postoperative sponge and instrument counts have been routine for decades. There is no single standard, although nursing and surgical organizations have developed best practices for sponge, needle, and instrument counts. 
Different ways of counting sponges may be used in the same operating room even during the same case, says the Association of Operating Room Nurses. This lack of standardized practice creates opportunities for errors. 
A US Department of Health and Human Services study says that this type of mistake occurs in 1 in 100 to 1 in 5000 persons. A 2008 study published in Annals of Surgeryfound that mistakes in tool and sponge counts happened in 12.5% of surgeries. 
Nursing and surgical groups recommend that each member of the surgical team play an equal role in assuring accuracy of the counts. Recently, manufacturers have made sponges with threads visible on x-rays, radiofrequency identification systems, and bar coding to alert staff about missing sponges. 

 
As a young child, Betty had been given penicillin, turned blue, and was rushed to the hospital. She was 15 when she got strep throat, was given penicillin, and died. No one had asked her about medication allergies. 
Medical questionnaire forms have always included a space for allergies, although this became much more prominent after the Institute of Medicine report on patient safety in 1999. 
In 2008, the Pennsylvania Patient Safety Advisory cited more than 3800 cases in which patients received medications to which they had documented allergies. Breakdowns in communication of allergy information include "documentation of patients' allergies on paper but not entered into the organization's computerized order-entry systems, and allergies arising during episodes of care but not documented in the medical record or communicated to appropriate staff." 
Strategies to address the problem include adding visible prompts in consistent and prominent locations listing patient allergies, eliminating the practice of writing drug allergens on allergy arm bracelets, and making the allergy reaction selection a mandatory entry in the organization's order-entry systems. 


 
Linda wasn't doing well in her first trimester. The nausea and vomiting left her severely dehydrated and with a low potassium level. In the emergency department, her nurse made a mathematical error and administered too much intravenous potassium. Within an hour, Linda was dead. 
In the 1980s and 1990s, patient safety groups, including JCAHO, drew attention to the need for removal of concentrated potassium chloride vials fr om patient care areas. Now, almost all US hospitals have removed the drug from floor stock on patient care units. Potassium is now added to IVs by the manufacturer and is labeled. 
The tragic errors that gave rise to this system change were caused by deficits in knowledge about the dangers of rapid intravenous administration of concentrated potassium or, more often, mental slips or selection errors when grabbing a vial of medication. Lim iting access to this drug has reduced fatal errors. 
Additional safety strategies include using premixed solutions, segregating potassium from other drugs and using warning labels, prohibiting the dispensing of vials for individual patients, and performing double-checks with a pharmacist. 


 
Frank was 72 years old when he broke his right leg in a car accident and had to recover for a few weeks in a rehabilitation facility. The nurses didn't know that patients needed to move regularly, and Frank developed deep decubitus (pressure) ulcers. When these became infected, Frank's leg had to be amputated. 
Each year, more than 2.5 million people in the United States develop pressure ulcers, notes the Agency for Healthcare Research and Quality. Bedsores can be fatal. The Centers for Medicare & Medicaid Services no longer provide additional reimbursement to hospitals to care for a patient who acquires a pressure ulcer while under the hospital's care. 
The primary way to prevent decubitus ulcers is by turning the patient regularly, usually at least every 2 hours. Efforts to relieve pressure to avoid additional sores by moving the patient have been documented since at least the 19th century. 
Nursing homes and hospitals now have programs to avoid development of bedsores by using a set timeframe to reduce pressure and having dry sheets by using catheters or impermeable dressing. Pressure shifting on a regular basis and the use of pressure-distributive mattresses are now common practices. 


 
Lillian was 68 years old and weighed 250 lb when she underwent surgery to remove her gallbladder. The second day after surgery, she needed help to walk to the bathroom. Lillian's nurse, Millie, wasn't strong enough to support her and they both fell, breaking Millie's right arm and Lillian's left leg. 
Historically, schools of nursing have taught students to manually lift patients using proper body mechanics, such as lifting with the legs and using correct posture. However, body mechanics are not sufficient to protect nurses from heavy weights, awkward postures, and the repetition involved in manually lifting patients, according to a position paper from the American Nurses Association (ANA). 
The ANA supports policies that eliminate manual patient lifting. Safe patient-handling techniques involve the use of such equipment as full-body slings, stand-assist lifts, lateral transfer devices, and friction-reducing devices. 
There is no federal legislation or regulation on safe patient handling, although several states have enacted such legislation, ANA says. 


 
When Christy was 42 years old, her doctor discovered a large lump in her left breast. The lump should have been evident during Christy's 2 previous annual examinations if they had been complete. By the time it was diagnosed, the cancer had progressed beyond cure. 
Breast examinations by the physician, teaching of techniques for breast self-examination, and recommendation of mammograms are now the standard of care. 
Mammography was developed in the 1950s and became a common diagnostic tool in the 1960s. It is a key method for detecting breast cancer early, when it is easier to treat. In 2005, about 68% of all US women between 40 and 64 years of age had had mammography in the past 2 years, according to insurance studies. All US states except Utah require private health insurance plans and Medicaid to pay for breast cancer screening. 
Standards for the timing of mammography vary by organization and by patient history. The US Preventive Services Task Force currently recommends that low-risk women older than 50 years receive mammography once every 2 years. ACOG currently recommends annual mammograms for all women 40 and older. 


 
These are but a few examples of medical mistakes that have led to patient injuries or death -- and have led further to changes in the way physicians in the United States practice medicine. Recognizing that all of these mistakes could have been prevented, the federal government and various medical academies have developed guidelines for prevention and treatment of many diseases. 

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