Avoiding Hospital Blunders (Knowing the Risks and Speaking Up Can Help You Stay Safe)
Copyright 2000 Consumers Union of U.S., Inc.
Consumer Reports On Health
SECTION: Vol. 12, No. 6, pp. 1, 3-5
Medical errors are alarmingly common – but patients themselves can provide a key safety check, according to the National Academy of Science’s Institute of Medicine.
It’s ironic that modern hospitals, which ease suffering and save countless lives, can also be dangerous places that hurt the very patients they’re supposed to help. Each year at least half a million hospital patients are harmed or killed by mistakes that doctors, nurses, and other staff members make, according to recent estimates. At least 3 percent of hospital patients – probably far more – suffer an adverse event serious enough to lengthen their hospital stay. Roughly half of those events are preventable, according to a large Harvard study. Even by the lowest estimates, hospital errors are the eighth leading cause of death in the U.S., ahead of car crashes, breast cancer, and AIDS.
Some hospital dangers seem to go with the territory. Hospitals are breeding grounds for infection, including potentially deadly infections resistant to antibiotics. That’s because hospitals house many infected patients and many more who catch infection easily because their immune system is compromised or because invasive devices, such as needles and catheters, can carry germs into the body. Another important danger: Medication mix-ups. The average hospital patient receives ten different drugs; these often have look-alike labels or sound-alike names, and are prescribed by many different specialists who either don’t communicate with one another or who leave notes in cryptic handwriting.
Human error – which exists everywhere – can be disastrous in hospitals. Doctors and nurses who fail to wash their hands between patients can spread infections. Busy nurses may mistake micrograms for milligrams and give wrong drug doses, or mistake one patient for another and give the wrong drug. Surgeons occasionally forget to remove a sponge or clamp before sewing the patient up; a few have even operated on the wrong side of the body.
The Harvard study of adverse hospital events tallied only the errors that actually got recorded on medical charts – and thus almost surely underestimated the problem. In another recent study at a large Chicago teaching hospital, trained observers followed doctors on their daily rounds and attended all daytime staff meetings for nine months. Using the same criteria as the Harvard researchers did, the observers found a serious-error rate of 18 percent among surgery patients. Similarly, estimates from the national Centers for Disease Control and Prevention suggest that the number of infections developed in hospitals – one of the most common and preventable adverse events – is about 20 times higher than the number found in the Harvard study.
Last December the national Institute of Medicine recommended sweeping changes to combat hospital errors. They include requiring hospitals to report serious mistakes to the government, to make the institutions more accountable. The institute also urged hospitals to launch comprehensive patient-safety initiatives, such as having pharmacists accompany doctors on their rounds and having doctors type all their prescriptions into a computerized screening system.
Patients also have a key role to play as a “safety check” on their own behalf, according to the institute’s report. If you’re facing hospitalization, prepare to take steps to protect yourself and to involve a friend or relative to help out, particularly when you’re sick or sedated.
Here’s how to make sure your doctors and nurses take the steps that can help prevent errors and make your hospital stay safer and more comfortable.
PREPARING FOR A HOSPITAL STAY
Before checking into a hospital, have a detailed discussion with your doctor. If possible, bring along a friend or family member who can help you recall and articulate your questions, remember or record the answers, and assert your preferences. Here are some key questions to ask:
– Which pre-op tests do I really need? Many hospitals reflexively subject surgery patients to a plethora of preoperative tests, some of which may not be truly necessary. In addition, needless tests may yield false positive results that necessitate other, sometimes hazardous tests. Healthy adults under age 40 generally need only a simple blood count and, for sexually active women, a pregnancy test. Healthy people older than 40 may need a few additional tests, such as an electrocardiogram plus blood tests for diabetes and kidney or liver disease. Ask your doctor whether you can skip any pre-op tests that aren’t absolutely necessary. Also ask what other tests you may need while you’re in the hospital. That can help give you the confidence to object if someone wants you to undergo an unexpected test that makes no apparent sense.
– Which drugs should and shouldn’t I get? Ask your doctor to help you compile a list of all the drugs you’ll probably need in the hospital, including those you’re already taking plus any new ones you’re likely to receive. The list should include the name, purpose, dosage instructions, and, if possible, the color and shape of the pills you may get. Take the list to the hospital so that you or the person watching out for you can ask for an explanation if you’re given a drug that you don’t expect, or fail to get one that you do. In addition, ask your doctor to leave standing orders for drugs to treat insomnia, constipation, and pain so if the need arises you won’t face a long wait while the nurse puts in a call to your doctor.
Avoid aspirin and any other nonsteroidal anti-inflammatory drugs such as ibuprofen (Advil, Motrin) for one week before surgery. And avoid herbal remedies or dietary supplements for two weeks before any hospital admission. Those drugs and many supplements – including garlic, ginkgo biloba, and vitamin E – may increase the risk of blood loss during and right after surgery. And some supplements, notably St. John’s wort (see “Drug notes”), can interfere with prescription drugs and anesthesia.
– Can you help me through the night? Patients are often awakened to have their blood pressure and temperature taken repeatedly during the night. Ask your doctor if any of those tests can be put off until the morning.
– Who’s in charge? Several specialists will probably examine you in the hospital. To minimize the chance of overlapping or conflicting orders, insist that one doctor coordinate your treatment. Ideally, your primary doctor or one of his or her colleagues should visit you daily.
PREPARING FOR SURGERY
The questions below may sound as if you’re asking for special privileges. But physicians are getting used to such requests and shouldn’t mind, provided you ask in a friendly manner.
– Can I schedule my surgery? Hospital staffing can be skimpy at night and on weekends. Non-emergency procedures slated for Monday sometimes get delayed or bumped due to spillover of emergency cases from the weekend; when surgery is done on Friday, you may get reduced postoperative care on the weekend. So ask if you can have your surgery on a Tuesday, Wednesday, or Thursday.
Similarly, ask whether surgery can be scheduled in the morning. That way, the immediate postoperative hours, when you need the most care, will come on the day shift, when the staff is at full strength. In addition, hospitals typically prohibit eating and drinking for at least eight hours before general anesthesia. That ban usually starts at midnight, so the earlier the operation, the shorter your fast will be.
– Will I need a transfusion? The risk of being infected by a blood transfusion is extremely small. But if your surgeon says you’ll probably need blood, you may want to eliminate that risk entirely by banking your own blood supply ahead of time.
– Would you autograph my leg? Reports of surgeons removing the wrong limb or kidney, or operating on the wrong side of the brain, periodically create alarming headlines. While such errors are rare, they occur often enough that the American College of Orthopaedic Surgeons advises its members to initial the surgery site beforehand. If your surgeon doesn’t offer to mark the site, ask for it.
– Do I need antibiotics? Overuse of antibiotics has spawned swarms of drug-resistant bacteria. But experts worry that some physicians may now be overreacting to the problem and underusing antibiotics. If the surgeon says your operation poses a significant threat of infection, ask him or her to make sure you receive antibiotics in the hour before surgery – a timing that isn’t always followed.
– How will my pain be controlled? Many patients still suffer needlessly from significant postsurgical pain, for several reasons. Some surgeons are reluctant to order morphine or other opiates, the strongest painkillers, even though the chance of addiction is minuscule. Or they fail to consider newer options, such as epidural anesthesia, which controls pain by feeding a nerve-blocking drug into the spine. Nerve blockade may be preferable to opiates after certain operations, such as joint replacement, since it controls pain equally well but doesn’t make you groggy. In addition, most hospitals now have patient-controlled intravenous analgesia (PCA), which lets you administer your own medication by pushing a button on a computerized pump.
Surgeons and hospitals don’t always offer these options unless patients ask for them. Ask your surgeon and anesthesiologist to develop a plan for controlling your pain, including the use of PCA if appropriate. If it is, ask for proper training, preferably given both before and after surgery.
Certain self-help steps may provide further pain control and even reduce the need for pain medication in some cases. In a recent study, surgery patients who listened to soothing music through headphones while recovering reported less pain than other patients. Other relaxation techniques – such as deep breathing, muscle relaxation, or listening to guided imagery or self-hypnosis tapes – may also be helpful.
TALK WITH YOUR NURSE
If you can afford it, consider hiring a private-duty nurse. But even with staff nurses, you or the friend or relative who’s watching out for you should expect reasonable and timely responses to reasonable requests and questions. Remember that the hospital staff is often overworked, and complaining too often or too aggressively about minor delays and inconveniences may backfire and convince the staff that you’re a malcontent. Still, the Patient’s Bill of Rights – a code of conduct developed by the American Hospital Association – guarantees your right to insist on appropriate action. For patients who don’t get satisfactory responses, most hospitals now have patient advocates and social workers on staff who can intervene.
These questions may help persuade the staff to follow through on crucial steps in your care.
– Did you wash your hands? Studies suggest that many nurses and doctors fail to follow this essential practice. If you don’t see the person wash her or his hands with soap (or don gloves) before touching you, politely ask whether she or he has done so.
– Did you check my wristband? When you check in, make sure the information on your wristband – your name plus any drug allergies – is accurate. Nurses should check the band carefully each time they give you any drug. If the nurse doesn’t, it’s wise to mention your name and your allergies.
– When can I walk? Walking as soon as possible after surgery helps reduce the risk of potentially dangerous blood clots in the legs. Ask your nurse – or a friend or relative – to help you take a stroll. If you’re overweight or have varicose veins, ask for special elastic stockings or other compressive devices to wear during your recovery.
– Do I still need the catheter? The risk of urinary-tract infection increases significantly if the urinary catheter is left in place for more than two or three days. If you’re still using a catheter 48 hours after surgery, find out whether it should be removed. If you start feeling urinary discomfort, ask your nurse to check whether the catheter is clogged. And tell your nurse if your intravenous (IV) line starts leaking or if you develop pain or swelling in your arm.
– Where’s my spirometer? Lung-strengthening exercises, using a device called an incentive spirometer, can reduce the risk of pneumonia after major surgery. If your nurse doesn’t give you one or doesn’t teach you how to use it, ask your doctor about it.
GET READY FOR HOME
Patients often leave the hospital sooner and sicker than in the past. That makes planning for your discharge essential; you should be visited by a discharge planner as soon as you check into the hospital.
Ask your doctor, surgeon, or discharge planner for a list of the medications or devices you may need when you get home, and for instructions on how to use them. Next, discuss how to prepare your home for your convalescence. For example, you may want to move to a downstairs bedroom, get an elevated toilet seat, move obstructing furniture out of the way, and remove throw rugs. Finally, find out whether you’ll probably need physical therapy, home nursing care, or a temporary stay in a rehabilitation facility. Once you check into the hospital, ask to speak with the hospital’s discharge planner (and ask your doctors to do the same), so the hospital can start arranging for the appropriate services.
If the hospital tries to discharge you before you feel ready, insist on talking first with your doctor. You shouldn’t go home if you feel disoriented, faint, or unsteady, have pain that’s not controlled by oral medication, can’t go to the bathroom unassisted, or can’t keep food or drink down. If your doctor isn’t able to extend your stay, ask to speak again with the discharge planner or with the patient advocate. If necessary, contact your insurance carrier and the hospital administration. Hospitals are legally required to provide Medicare patients with a toll-free number they can call to appeal discharge decisions.
To optimize a hospital stay:
– Enlist the help of people who can watch out for you while you’re in the hospital, including a friend or relative, your primary-care doctor, and, if necessary, the hospital’s patient advocate or social worker.
– Talk with your doctor about eliminating needless preoperative or nocturnal testing.
– Ask your surgeon about the optimal timing for surgery and preventive antibiotics, and about options for transfusions and pain control.
– Check your medications each time and ask for an explanation if any are unfamiliar.
– If necessary, remind the nurses and doctors to wash their hands, check your wristband, catheter, and IV line, and get you walking again.
– Object strenuously to attempts at premature discharge. Obtain complete information about convalescing at home.