101 Ways to Prevent Medical Errors

 

Bioterrorism Attack!  Is Your Health Care Institution Prepared?

by 'Yinka Vidal author of 101 Ways to Prevent Medical Errors

Hospitals have been conducting disaster drills for so many years just in case of a real disaster. These drills are designed to prepare the hospitals to handle a large number of patient casualties from natural disasters or traumas. Are these hospital drills good enough to handle thousands of possible bioterrorism or chemical attack casualties? Based on the results of our study instituted over a period of three years to reduce medical errors, it is fair to conclude that health care institutions are inadequately prepared. Many of them are unprepared to handle a large number of patient casualties which may be expected during an attack. Reduction of medical error remains a great challenge for some hospitals let alone able to handle a large number of patients  at one time. The purpose of this article is to raise the awareness of health care administrators across the nation about how to test the preparedness of their respective institutions in such a disaster.


Anticipation of problems
The government and the public health department's readiness is different from the readiness of individual health care facilities. Health care workers are going to be on the frontline battle of bioterrorism attack while receiving and treating patients. How is each hospital prepared to protect each worker? Regardless to the public health department's preparation, if individual health care facilities are not prepared, a bioterrorist attack in just one city may lead to a high number of patients. The central issue is the state of preparedness of each institution to handle a very large number of casualties. For example, since the Institute of Medicine's report of December 1999 about the increase number of preventable deaths due to medical errors, there are still serious systemic problems in health care institutions across the nation. While some of these institutions are working to reduce error rates, many have not quite achieved their objectives while others are still struggling.

To understand the nature of the problems faced by these institutions, think about the present number of system failures leading to medical errors. Think about how the wrong patients are chosen from the computer and registered in  some hospitals across the nation. Consider how many patients are admitted to hospitals and sent to rooms without identification arm bands. Estimate  the number of wrong medications given to patients due to misidentification. In one hospital, during our study, an emergency room was reported to have a minimum of 10 unlabeled blood specimens sent to the laboratory each week. The same emergency room had over 1,000 incidents of specimen misidentification in one year while handling less than 20 patients at one time. Imagine the same emergency room faced with the task of handling 5,000 to 10,000 patients at one time. The worse mistake is to assume that a perfect system is in place to handle any unforeseen casualties.


Challenges faced by a hospital laboratory after the terrorist attack
The thesis of this article was not selected from a conjectural analysis following the terrorists' attack of September 11, 2001, as we have seen and heard all over the media. This report is based on actual incident which happened. According to Pamela Tatapchak,  of Advance for Medical Laboratory Professionals, Sept., 2001, on the morning of the attack, the New York Presbyterian Hospital was placed on level 1 alert being one of the largest burn centers in the city. Between 11:00 a.m. to 12 noon, critical patients started arriving through the hospital's emergency room. The first challenge faced by the laboratory was to shut down certain routine services and focus only on the "disaster urgent testing menus." One of the biggest challenges was numerous blood specimens arriving in the lab without being properly registered. Many of the phone lines were severed and communication between hospital departments was impossible. It was therefore difficult for the lab to match the test requisitions with patients' results since most of them arrived as John Does with a number.

Another challenge was the  shortage of staff needed to handle the volume of work. By September 13, more than 100 patients had been admitted, most of them in critical condition. Between the continuum services of Beth Israel Medical Center and St. Luke's-Roosevelt Hospital Center, 551 patients were treated while 84 of them were admitted. In all, according to the New York Hospital Association which included about 200 hospitals, more than 1,500 patient were treated from various hospital emergency rooms during the aftermath of the terrorist attack of September 2001.


The implication of medical errors
Based on estimation, if there is bioterrorism or a true threat of such a disaster, a hospital system may be faced with treating more than ten folds the number of patients compared to the number of victims from the September terrorists attacks. Is every hospital and health care system in the nation ready to handle the anticipated volume of patients in a bioterrorism attack? Today, many hospitals are still struggling with how to solve the systemic problems of medical errors. It was reported that not only has the government funding for public health diminished over the years, staffing needs at various hospitals across the nation are only tailored to current patient population due to cost containment.

The anticipation of possible bioterrorism has made medical errors and hospital staffing to be critical issues needing immediate attention. Perhaps the federal government may need to give financial assistance to help some hospitals prepare for bioterrorism attack. Granting that specific problems of medical errors are unique to different health care institutions. If the systemic problems which are the root causes of these medical errors are not immediately addressed, a small scale bioterrorist attack in a metropolitan area may lead to a monumental medical catastrophe of unpredictable dimension.


Can we learn from a sequence of events?
In 1994, Air France 8969 was hijacked as the terrorist planned to crash the plane into the Eiffel Tower in Paris. In 1986 a Pam America Airliner was about to be crashed in Israel by the terrorists. The attempt was unsuccessful even though the plane full of fuel was about to be used as a flying bomb. In 2001, the terrorists accomplished their objective as the the twin towers of the World Trade Center were demolished using airplanes full of fuel as flying bombs. Sad as these events, we sometimes do a bad job of problem anticipation. Similarly, hospitals and health care institutions across the nation should learn from these events. How prepared is your health care facility to handle bioterrorism or chemical warfare?


Hospital preparedness
Perhaps all hospitals should train as many health care workers as possible including all nursing, laboratory and pharmacy staff on how to give injections just in case there is a need to vaccinate thousands of patients at one time. Hospitals should also institute a plan to mobilize health care workers from other institutions within the network to the location of those hospitals affected by the disaster.  Many questions need to be raised. How will health care professionals be protected especially when they are thrown on to the front line of a bioterrorist attack? If correct specimen labeling is a problem for some hospital departments when handling less than 20 patients, how will such a system handle over 500 patients at one time without making serious mistakes?


Anybody who has worked in any emergency room knows the exuberant dedication and enthusiasm of health care workers at a time of joint efforts in a race with death. Despite this dedication and specialized training of these workers, a poorly designed health care system is doomed during an actual disaster with many casualties. Without fooling ourselves as health care professionals, we have serious systemic problems within our institutions leading to preventable medical errors. As part of our preparedness, systemic problems within various hospitals need to be addressed with great urgency.
Helpful links:


Book on the Prevention of  Medical Errors: 

Order the Book: 101 Ways to Prevent Medical Errors

Hospital Seminars on the Prevention of  Medical Errors

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Last modified: July 17, 2010