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Study finds errors in post-surgery care are common

By Kerry Grens

NEW YORK (Reuters Health) - If the norm at one large urban teaching hospital is any indicator, surgery patients can expect to experience between four and five procedural mistakes - half of which will cause them real harm - during their post-op recuperation, according to a UK study.

Hospital safety researchers at Imperial College London monitored all patients at a "large gastro-intestinal surgery center" over the course of two years and found that failures in the "processes" of care - from administering drugs, to delivering test results and giving patients instructions - were rampant. And 51 percent of the instances led to serious problems.

"I think that's simply astonishing and shocking in this day and age of patient safety protocols, and my main take home message from this study is that our current patient safety protocols do not keep our patients safe," said Dr. Philip Stahel of Denver Health Medical Center, who was not involved in the study.

Though the new research was done at one hospital in the UK, Stahel, who specializes in patient safety, said he believes the findings are representative of busy teaching hospitals in the U.S.

To uncover errors at a hospital is no surprise; numerous studies have documented how often mistakes happen in an effort to address their root causes.

Much of the previous research has focused on one type of error, however, or only on those with a negative impact on the patient, according to Stahel.

The new research tracked the hospital care of 50 patients who underwent non-emergency surgery on the digestive tract, mostly for cancer, between 2008 and 2010.

On average, the patients stayed in the hospital for 11 days, and the researchers made daily observations to monitor how well medical staff followed standard procedures.

The team identified 352 mistakes, 256 of which were due to what they called "process failures."

"Failures had many causes but two of the most common and preventable were failures in communication between staff and delays in treatment or assessment," said Charles Vincent, a professor at Imperial College London and one of the authors of the study.

For example, one error the researchers uncovered involved a five-hour delay in giving a drug to a patient. It should have been delivered at 6 PM, but because the patient had a minor procedure performed at 5 PM, staff apparently forgot the medication and didn't deliver the prescribed dose until 11 PM.

In another instance, the initial results of a scan were considered normal, then later revised to flag a problem. But the surgical team never received the revised report.

Half of the process errors led to harm or increased the length of a patient's hospital stay, though none of the patients died or suffered a lasting disability as a result of a mistake.

Still, the UK team wrote in the Annals of Surgery, 85 percent of the process failures were preventable and three quarters of those that led to patient harm.

Stahel said that one of the ways to prevent mistakes is to implement safety procedures, such as so-called read-backs and checklists.

Read-backs involve repeating the instructions of another clinician to make sure it was communicated accurately.

A checklist helps ensure that no step in a patient's care is overlooked.

One recent study found the use of surgical checklists was tied to a drop of nearly 50 percent in surgery-related blood clots and infections (see Reuters Health story of December 20, 2011).

Vincent cautioned that checklists are not a complete solution.

"Checklists are unlikely to prevent all failures in this study as (a) patient's post-operative treatment is highly variable and therefore not easily covered by a single checklist (or even many)," he told Reuters Health in an email.

Stahel noted that medical staff also have to buy-in to patient safety measures to have them be successful.

"Protocols alone cannot keep patients safe, we need a culture (of safety)," he said.

SOURCE: http://bit.ly/PU5OFZ Annals of Surgery, online September 20, 2012.

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