The Secret of Great Health Care
The Institute of Medicine estimates that in 1999, 44,000 to 98,000 Americans die each year by mistakes in the hospital (1). In addition to death, other complications and increased health care costs contribute to the dire state of the American hospital system. Complications, including errors, cost the American health care system billions of dollars each year.
Hospitalization is typical and often necessary when individuals are acutely ill, but it is fraught with risks. Hospitalization is not always required to treat disease, but at other times it is the only way to go, as many disease states cannot be managed without extensive monitoring and testing. This chapter discusses the risks and ways to avoid complications and errors in the hospital. Each individual needs to be organized during his or her hospital stay and be involved in the care.
Risks of the Hospital
The hospital is a dangerous place. The risks of hospitalization can be subdivided into complications of hospitalizations, errors and iatrogenic disease. Complications are occurrences that result from some aspect of the hospitalization. Errors are mistakes that doctors, nurses or other staff members commit. Iatrogenic disease, defined as disease produced by doctors or other health care workers, runs rampant in the hospital.
You may be thinking, “Doctors don’t cause disease”. Yes they do. It is extremely rare that they would do this purposely but doctors and health care providers frequently cause disease unintentionally, common examples of iatrogenic disease include infections, side effect or complications of a medication, such as major bleeding or kidney failure from a diagnostic procedure.
Complications
Complications of hospitalization are more common in the older population. Risk factors for complications in the hospital include recently living in a nursing home, older age, increased number of drugs, poor health and longer length of stay. Risk factors of physical or mental decline during a hospitalization include age greater than 75, dementia, inability to perform activities of daily living such as bathing or cooking, social isolation and poor physical functioning such inability to walk independently.
Complications of hospitalization consist of sun downing, falls, excessive bed rest, pressure sores, malnutrition and increased dependency. Sun downing, which commonly occur in those with dementia, is an increased amount of confusion often associated with agitation or other behavior disturbances that occurs at nighttime. Those without diagnosed dementia who suffer sun downing in a new environment are often diagnosed shortly thereafter with dementia. Sun downing increases the risk of problems such as falls, use of restraints (tying the patient down) or excessive use of medicine to control behaviors.
Bed rest in the hospital is commonplace. Sometimes it is necessary to prescribe bed rest but usually getting patients up and moving is the best strategy to prevent complications. Bed rest breeds dependency, which leads to further complications including debility after hospitalization. The risk is even greater in those who are older and have a baseline lower level of functioning.
The hospital is an environment where many people, with older individuals being at greater risk, lose their sense of identity. Patients are thrown out of their daily routine - not eating their own food, not sleeping in their own bed and not taking their own medicine. These changes are enough to get some patients sicker. Increased confusion is a very common problem seen in older patients when changing environments.
Pressure sores, more commonly known as bedsores, are a frequent complication of a prolonged hospitalization. Hospitalized patients are at increased risk for pressure sores due to bed rest, poor nutrition and dehydration. Pressure sores can be prevented with good nursing care including assuring good nutrition and getting the patient up to walk. Getting up is something that many hospitalized patients do not do, especially ones who are extremely ill. If you have not been getting up, encourage the nursing staff to get you out of bed. If you are unable to get out of bed make sure you are getting turned frequently (at least every 2 hours) or placed on a specialty mattress to reduce pressure on areas of your body.
Malnutrition is common among hospitalized patients. Patients in the hospital are sick are not eating well. In addition, disease states increase the rate at which your body uses energy, so eating the amount of food you normal eat may not be enough to maintain body weight and promote healing. Eating a diet that is different then the food you eat at home often leads to a voluntary decrease in food intake and weight loss.
Bringing your own food can sometimes prevent not only malnutrition but also other illness and expense. Before doing this always check with your health care provider, as many hospitalized individuals require special diets. For example, after a stroke patients often need food that is puréed to prevent the food from sliding down into the lungs and causing pneumonia.
Falls are a frequent occurrence among hospitalized patients. Hospitalized patients fall due to weakness from illness, mobility restriction from intravenous lines, sedation due to new medicines, and getting up to go to the bathroom without assistance. Often falls result from a combination of factors such as weakness secondary to the disease process that the patient is admitted for, combined with an unusual environment.
New medications can lead to falls. For example, new blood pressure pills can result in dizziness or unsteadiness. Water pills can lead to increased urination especially at night. When the urge to urinate comes on at night a patient trying to maneuver to the bathroom in an unfamiliar environment increases risk of falls.
Taking responsibility for your safety consists of asking for help when ambulating and knowing the medicines you are on and the risk they pose for falls.
Errors
Medications
Complications from medicine can be broken down into errors and side effects. Side effects are reactions that result from a medication or treatment. Many times side effects are expected but the doctor decides that the risk of the side effect is worth the benefit of the treatment. All medicines have side effects, but some are much more dangerous than others. When taking new medicines be aware and report unusual sensations to your doctor or nurse. Some common medicines used in hospitals require special attention.
Errors are mistakes made by a health care professional. Most medication errors are due to lack of attention not lack of knowledge from patients and staff.
Admission to the hospital is a common place where medication errors occur. Patients are often admitted to the hospital by a physician who is unfamiliar with his or her past medical history. Therefore, the admitting doctor relies solely on the patient’s report of medications when prescribing medications that the patient will take in the hospital.
If the patient does not provide an accurate list of medications then he or she will not get all of the medications necessary to keep their body in balance. Patients who are admitted to the hospital are in a weakened state due to their underlying illness and typically need all of the medications that they are on at home to keep their body balanced.
Consequently, when a patient is admitted to the hospital, the patient can make a significant positive effect on the number of errors. Accurately reporting the medications that the hospitalized patient is currently taking is a critical step in preventing errors. This is best accomplished by providing the admitting doctor with your personal health care record.
Patients getting the wrong medications are another form of error common in hospitalized patients. Nurses are very busy and care for multiple patients who they are unfamiliar with. Patients getting the wrong medicines are an occurrence that can be prevented. The best way to prevent yourself from getting the wrong medicine is to keep track of what medicines you get. Maintaining the hospital chart is one method to track your medications.
Misdiagnosis
Misdiagnosis is common in the hospital. Medicine is not an exact science; it is a combination of art and science. Coming up with the correct diagnosis is important to prevent progression of disease and the possibly death and disability that can accompany disease. Some diseases are more easily diagnosed than others. Cooperation from the patient can significantly aid the doctor in making a speedy and accurate diagnosis. Accurate reporting of the past medical history and current symptoms, asking the right questions and making sure you are getting optimal care reduces the chance your doctor will diagnose you incorrectly.
Discharge
Errors on discharge are common. When being discharged from the hospital the patient receives discharge instructions including a list of medications. Comparing this list of medicine to your personal hospital chart, that you have been keeping during your stay, can aid you in assuring there are no errors on discharge. When you are given your discharge instructions, compare the medication list with the list of medicines you were given in the hospital, on your hospital chart. If they do not match up question the discharge nurse or the doctor for clarification.
Hospitalizations are times that medications are adjusted. The patient often assumes that medications not on the list are ones that were discontinued in the hospital. Many times this is the case, but many times medications were accidentally left off. Errors occur far too commonly on discharge. Nurses, doctors and other health care professionals taking care of you are who are all very busy. Oversights and omissions occur even with the best-intentioned health care providers. Your best defense is to closely monitor your medical care. No one has your best interest in mind more than you.
Follow up appointments commonly get missed after discharge. Discharge instructions should include a scheduled appointment with your doctor or a number to call to set up that appointment. Make sure that this appointment is carried out. This can mean the difference between life and death. New medications are often started in the hospital and require outpatient monitoring to assure they are not only effective but also not causing any life threatening complications.
Discharge Steps
Iatrogenic Disease
Infections
Two million hospitalized patients suffer from hospital-acquired infections each year (2). Hospital induced infections are also known as nosocomial infections, which not only increase the cost and length of your hospital stay but increase the risk of dying in the hospital. Nosocomial infections cost the American health care system billions of dollars a year. Infection rates vary a lot by hospital, so it is important to be informed about which hospitals are most risky. Contact your local health department to determine which hospitals have the lowest incidence of hospital-acquired infections.
Most common types of hospital-acquired infections are urinary tract infections, severe diarrhea, pneumonia and blood stream infections. There are bacteria and viruses in the hospital that most patients have not been exposed to and are susceptible to. Most hospitalized patients have a suppressed immune system due to their illness and have a more difficult time fighting infections.
Many of these infections can be prevented. The most important step to prevent hospital-acquired infection is to make sure everyone who gets close to you washes his or her hands. It is important that you insist every person who takes care of you washes his or her hands prior to putting hands on you.
Invasive procedures, which are actions where some type of instrument is introduced into the body, may initiate infection. Examples of invasive procedures include: urinary catheterization, inserting intravenous lines and cardiac catheterizations. These procedures are typically done under sterile technique so no bacteria can enter into the body. These procedures are done by busy nurses and doctors who at times may not follow the proper technique and may introduce bacteria into the body. The hospital is an environment with a lot of bacteria floating around. This increases the risk of getting infections during these procedures.
Infections often result because a disease is spread from another sick patient. If your roommate is showing signs and symptoms of an infectious disease, ask to move rooms. Signs and symptoms you may notice that indicate infection include: coughing, diarrhea, runny nose, fever or increased confusion. Many infectious diseases are passed through the air or from touching something that the sick patient has touched or being in close proximity to someone with infection.
Diagnostic Testing
Unnecessary testing is a frequent occurrence. Diagnostic tests have risk including pain or discomfort, allergic reaction, bleeding or infection. It is imperative that you inquire about the necessity of each test that you have. Tests such as a CAT scan can save your life but it also provides a tremendous amount of radiation, which is a potential deadly side effects.
Commonly x-rays are performed to help diagnosis or rule out pneumonia but they are often not needed. Someone who presents with a runny nose, sore throat, cough and low-grade fever is unlikely to have pneumonia. In this situation an x-ray is sometimes ordered (especially in the emergency room) to rule out pneumonia even though pneumonia is unlikely. X-rays are generally safe tests but they are not completely benign as they do entail radiation exposure.
There are a number of steps that should be taken when diagnostic tests are recommended in the hospital. When the technician comes to take you for the test, you should ask, “who is this test for?” Errors may occur because the test is performed on the wrong person. Asking whom the test is for will decrease the chance of this happening. When your doctor recommends the test ask the questions listed in Table 7.
Table 6: Questions to ask when being ordered a diagnostic test
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Preventing Problems in the Hospital: Your Role
Some errors are just mistakes that you cannot do anything about no matter how knowledgeable, attentive or careful you are. On the other hand, many errors can be over come by being an informed consumer of health care, asking questions and trusting your instincts. It is important that you take responsibility while you are in the hospital to reduce the risk of complications. An educated and prepared patient is the best protection against medical error.
The first step in preventing medical errors in the hospital is to ask your doctor about the possibility of being treated at home. Many times hospitalization is necessary, but there are times when being treated as an outpatient is possible. Avoiding the hospital reduces the risk of complications, errors and adverse events.
Family Support/Patient Advocate
Family support is an important part of getting through the hospital experience with the best possible outcome. Family and friends can be an advocate for you. While in the hospital patients are sick and may not be able to be able to watch out for their own interests. Having a loved one around while in the hospital may not be possible 24 hours a day, but anytime a loved one is around can help. They can be an extra set of eyes and ears, help you ask questions and provide reassurance.
Families can also be seen as an extra burden by the hospital staff but this does not have to be the case. Families and friends who follow some simple rules can not only help the patient but also are seen as a positive factor by the staff. Family members need to be courteous and respectful. Hospitalizations are stressful times and families can become frantic and abuse staff members that are just trying to do their job. Remaining calm and treating the staff with respect will go a lot further in assuring that you or your loved one gets good care than being rude and abrasive. Bringing snacks into to busy nurses and staff goes a long way. Hospital staff members are often very under appreciated and providing a little bit of appreciation for the staff can help assure that your loved one gets some extra attention while in the hospital.
Hospital chart
Medical errors are common - and at times fatal - in the hospital. To prevent errors and help the health care team - keep your own personal chart. Hospitalized patients are often not well enough to keep great notes on their illness so it often requires a family member to help in this process.
Your hospital chart is nothing more than a couple pieces of paper where key information is recorded. The personal hospital chart includes seven sections to monitor and follow your hospital course. Keep a copy of this by your bedside. As you read this section refer to the form.
The first section is where information is recorded about your doctors including: doctor’s names, how to contact them and times they round. Every time you see a new doctor record this information. It will allow you to keep information on, not only your primary care doctor, but also the specialists caring for you. Record information on the head nurse of the unit - nurses run the units and knowing who is in charge and how to contact them will help if a problem arises.
The second section is a place to record information about each doctor’s visit. This section is broken down into three sections: date, doctor, and comments on tests, labs and notes. Each time you see a doctor record the date and time in column number one and the name of the doctor in column two. The third column is for you to record any tests ordered and any comments that the doctor has made during the visit. Feel free to use more than one row to record comments or information on testing. This is the section that monitors, chronologically, your hospital course.
The third section is where your list of medicines are recorded. Medications are common sources of errors in the hospital. Helping the nursing staff by keeping a record of what medicines you take and when you take them assures you will get the proper medicine.
Keep in mind that there is some flexibility in the times nurses administer medicines. Nurses take care of multiple patients and are unable to give all 9:00 AM medicines to all of their patients at exactly 9 o’clock.
One of the most common errors in the hospital is missing a medication dose. Patient vigilance decreases this risk. Ask the nurse for a copy of your medication list. Record it in section three of the hospital chart. This list should match up with your list of home medicines but may include additions or deletions. Any medications that are on your hospital medication list but not on your home medication list or vice-versa should be questioned. It may be a purposeful omission or addition, but may be not.
On page two of the hospital chart record the medication’s dose and the time(s) it is administered. Place the date on the top row of the medication list. For each day record the time each day you received the medication.
In addition to knowing the names and times of all of your medicines you need to know why they are administered. Hospitalization is a time that new medications are often started and knowing why you are on these new medications is important. Discuss any new medications with the doctor who started the medication. Understand why you are on the drug, the side effects and the length of treatment.
Medications administered in the hospital are not always the same as medications that are administered at home. Sometimes medications are stopped when entering the hospital because they are worsening the condition in which the patient is being hospitalized for. For example, patients admitted to the hospital with pneumonia are often dehydrated. Dehydration is made worse by water pills that are common medications used to control blood pressure. Consequently, water pills are often stopped in those with dehydration.
As noted above there are many times when medications are purposely stopped, but there are also times that medications are inadvertently stopped. Hospital admission is a time when continuity of care is often broken. Patients are frequently taken care of by doctors who are not their primary care doctor. The new doctor is usually unaware of the medications that the patient is on. Unfortunately, medications are often not ordered in error.
A common drug that is omitted on hospital admission is antidepressants. After a few days being off this medicine – negative side effects can occur. The patient can develop nausea, dizziness, headache, which is a syndrome characterized by withdrawal of some antidepressants. This constellation of symptoms can be interpreted by health care providers as new symptoms that need to be worked up and can add to the number of days and dollars of your hospital visit. It is important that you are diligent about the medications that you are receiving in the hospital or you could be looking at extended hospital stays.
The fourth section is a place for you to take notes on any new diagnoses. Basic information is recorded in section two, but this section allows more room for details about the new diagnosis. Always ask for any literature that your doctor can give you about these diseases, but do not neglect to take notes as your doctor will be able to tell you how this disease affects you.
For example, if you are diagnosed with pneumonia, this is a place that you can record what treatments you are receiving for it and any notes that the doctor tells you. Studies indicate that patients forget most of what they are told immediately after it is told, especially in a stressful situation like the hospital.
The fifth section is a place for you to record more detailed information on blood work. Again, in section two record basic information. Always ask doctor to give you information about your blood work. For example, ask, “what blood work did you perform today and what specifically did it show”? Responses searched for include: your white blood count - which is a marker for infection - is improving or your kidney function is worsening. Ask for hard copies of the laboratory testing to include in your hospital chart. Later these copies can be placed in your personal health record.
The sixth section is a place to record information on testing performed during your hospitalization including x-rays, CAT scans, MRIs, ultrasounds or cardiac procedures. Again, ask the doctor for specific information, with a question like, “what did the CAT scan show”? Ask for a hard copy for your personal health record.
The seventh section is a place for you record information on any surgical procedures or other medical procedures that are performed. This could include a cardiac catheterization, thoracentesis, or biopsies. Ask the doctor for an interpretation and get a hard copy for your personal health record.
The eighth section is a place where you can record a list of questions as they arise. Continually update the list of questions as patients never remember all of the questions that they want to ask the doctor when he or she is in the room. The section includes questions you should be asking your doctor every day.
The last section is a general section where you can record general notes that do not fit anywhere else.
Key points
Below is a listing of the important steps to improve your health care while in the hospital.
