The concept of safety in medical services is a question that leads to a great career. It started with the US publication “Mistake – Man”, which means that error is man. The results of the study revealed the scale of the problem: medical errors affect up to 3-8% of medical services provided. The classic example of surgery on the wrong side of the body is found in 1 in 30,000 surgeries, for example in Europe, where 2,600 people a year make this mistake.
The scale of the problem prompted the search for corrective action. The aviation experience was very well solved by changing the security problem to “adverse events”, ie the way the errors started. The main principle is to analyze and learn from mistakes, not to focus on finding the culprits.
The course of this analysis can be defined as follows:
- The occurrence of an adverse event always requires an explanation of the reasons, which will lead to the absence of such an event in the future.
- An event reporting system is needed to draw conclusions.
- As in the field of aviation, everyone should be informed about the causes of the accident, so that such accidents can be prevented at home.
The condition of the operation on the wrong side of the body was carefully analyzed. Among the many reasons are:
- the surgeon examined the patient asleep, covering him with a towel;
- the location of the operating room was different from where it worked;
- worked with unknown personnel;
- spent overtime at work, etc.
After the analysis, it was found that simple solutions are enough to avoid simple mistakes. In the case discussed above, for example, a connection was established between the surgeon and the patient, who were able to speak together before the operation (and at bedtime) and determine the side of the operation. The problem of infection also returned, and its simplest solution, developed in the XIX century, was to wash your hands thoroughly.
This was of particular interest to us, as we have introduced very complex, multi-stage washing rules for all nursing procedures, such as blood draws, at LUX-MED. Medicine often comes in a full circle and is obvious, so forgotten will be even more important.
It is important that the doctor and nurse work with the patient on safety issues. Many complications can be prevented if all participants in the treatment process pay attention to the smallest details at a glance. Remember: making a mistake is a human thing, but not drawing conclusions from a mistake or not responding to attention that helps to avoid a mistake is not stupid, but a crime.