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The power of a checklist: preventing post-surgery errors

We all know that medical errors occur in hospitals in Ohio and throughout the country. Just two days ago we wrote about the terrible incident in which an Ohio nurse accidently threw away a donor kidney. These are the kinds of errors we think of when we talk about medical malpractice — the big, life-changing ones that happen during surgery. But recent research shows that the errors don't stop once the stitches are tied.

Published last month in the Annals of Surgery, the study shows that post-operation errors are extremely common. And while they may not have the same negative impact on patients as surgical errors, it's shocking to see that hospital staff regularly fail to follow standard, post-op procedures.

The study was carried out in London, but researchers say it's just as applicable to hospitals in the U.S. They studied 50 patients who had non-emergency surgeries on their digestive tracts and the hospital staff members who cared for them. Over the average of 11 days that each patient stayed in the hospital, researchers tallied 352 mistakes. More than 250 of those were deemed "process errors."

A process error refers to things like giving a patient his or her medication at the wrong time or failing to notify a surgical team of a change in a patient's condition.

Perhaps the most shocking part of the study results was that researchers said 85 percent of the errors they found were preventable — and 75 percent of those preventable errors caused harm to the patient. Fortunately, they believe there is a way to improve this problem.

Checklists and read-backs, they say can help prevent many of the errors they noticed in the study. Reading back instructions helps make sure they are clearly communicated and understood, and checklists help ensure no steps in a patient's care are missed.

Of course, that solution is not all-encompassing. According to one doctor, "Protocols cannot keep patients safe, we need a culture (of safety)."

Source: Reuters, "Study finds errors in post-surgery care are common," Kerry Grens, Oct. 2, 2012

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