The Secret of Great Health Care
The Institute of Medicine estimates that 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.
To highlight some of the problems with errors, a look at common problems in the hospital will be addressed.
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. 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.
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.
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.
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.
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
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. A physician who is unfamiliar with the patient’s past medical history often admits the patient to the hospital. 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.
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. 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 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. Hospitalizations are times that mediations 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.
Iatrogenic Disease
InfectionsTwo 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. Many 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. Busy nurses and doctors who at times may not follow the proper technique and may introduce bacteria into the body do these procedures. 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.
The health care system is laced with errors, complications and other problems. The hospital is a common place for these to occur, but they can occur in any setting. Being an involved health care consumer significantly reduces your risk of errors, complications or other adverse events.
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