This text-based course is a written transcript of the webinar, The Role of the Speech-Language Pathologist in Preventing Medical Errors, presented by Michelle Tristani.
After this course participants will be able to:
- Define 3 types of medical errors
- List factors that increase the risk of medical errors
- Describe strategies to prevent medical errors
- Outline steps of the root cause analysis
- Identify medical errors within the speech pathology scope of practice
Introduction and Overview
Welcome everyone and thank you for taking the time out of your day to join me on this webinar. While it is a dry topic, it is a very important topic. We need to make sure that we are adept at it so that we are equipped with the proper tools and policies and procedures, and some background information as well. Welcome to The Role of the Speech-Language Pathologist in Preventing Medical Errors.
Our agenda does mirror the objectives for the course, as does the post-test. First, we will talk about the history and awareness of mistakes, then the types of medical errors, error prevention and strategies to prevent medical errors, the role of the speech-language pathologist in preventing medical errors, and then we will get into risks and the potential for error. We will also discuss factors that increase the risk of medical errors; there are many, unfortunately. We will cover those and the potential for error in specific situations as a speech-language pathologist. Error resolution and root cause analysis will follow that.
Frequency, Cost and Causes of Medical Errors
How Frequently do Medical Errors Occur?
I would like to start by talking about how frequently medical errors occur. What truly are we up against? Unfortunately, going to the hospital is more risky than flying. If you are admitted to the hospital in any country, the chance of error is 1 in 10. The chance of dying due to an error would be 1 in 300. The risk of dying in an air crash is about 1 in 10 million passengers. Already you see the relevance and the importance of this topic.
What is the Cost of Medical Errors?
There are many other statistics and reports. This course does cover some of them for us. To continue, regarding the cost of medical errors, 1 in 20 patients has a hospital care related infection, 1 in 7 Medicare beneficiaries is harmed in the course of their care, and the estimated cost for this is 4.4 billion annually. Readmission to the hospital has been a hot topic for many of us and really has been pushed to the forefront. One in 5 Medicare patients that are discharged from an acute care hospital are readmitted within 30 days. In 1999 the Institute of Medicine estimated that as many as 98,000 people pass away every year from a preventable medical error, and 2009 had similar statistics. Now, there are other reports that discuss the increase, and that 98,000 is actually a lower number than what is currently accurate. We will cover that in just a moment.
Why do Medical Errors Occur?
Why does this happen? Healthcare is, as we know, a high-risk business. Many patients have multiple medications and multiple diagnoses. Unfortunately, healthcare is delivered in a very fast-paced, high-pressured environment. It also involves a lot of complex technology, and a lot of people. One cardiac operation can involve up to a team of 60 people, and it is about the same as what is needed to run a jumbo jet.
Research indicates that mistakes - and this is a relief to us – are not due to us not trying hard enough. They result, instead, from inherent shortcomings in systems, processes, policies, and procedures. Oftentimes it is not due to the person not trying hard enough. That is a bit of a relief. The Institute of Medicine also notes that many errors can result from a culture and system in a healthcare environment that is fragmented. Improving and rectifying errors and reducing mistakes, needs to be a team sport. It needs to be adopted by a culture that embraces apology and embraces disclosure. We will talk about that towards the end of our two hours.