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Your role in patient safety

  • Published
  • By Col. Bret Burton
  • 375th Medical Group Commander
She probably noticed me moving the varied ingredients around the bowl with my spoon, or my quizzical look and furrowed brow, or noticed the fact that she was halfway finished with her meal and I had not yet started consuming mine.

The fact was that my soup was cold.

But, so as to not ruin the date night with my bride, I decided to "keep it to myself." I could not have known the challenges in the restaurant's kitchen trying to meet my expectations--cooks who showed up late, too many customers showing at one time, equipment malfunctions, etc. But honestly, I wanted something very simple; I wanted hot soup and I wanted the restaurant to do it for me--otherwise it's back to ramen noodles in my own kitchen.

Health care consumers benefit from understanding some of the issues involved in providing them with trusted care; and there are some actions you can perform yourself to prepare for and learn about these issues. Doctors, nurses, and other health professionals dedicate their lives to caring for their patients. But providing health care can be complicated. There are often multiple steps involved in a health care visit.

A number of different medical staff may be take part in the care of a single patient, and patients may be confused by unfamiliar words and technical language. We understand that you trust us to get it right, the first time, every time.

Although hospitals, clinics, and offices take many steps to keep their patients safe, medical errors can happen. Often, medical errors (also called adverse events) occur when there is a single misstep in a chain of activities. The following areas of adverse events are more common than necessary; my hope is by presenting them to you, as an informed consumer, you will become aware of your role in a complicated system as we unite to keep you safe in healthcare.

Preventing "wrong procedures"

Performing the wrong procedure on the wrong site or with the wrong patient is an adverse event that can happen in locations with high volume of procedures or high turnover of personnel. Wrong-site surgery is rare and preventable, but it does still occur. Between 1995 and 2010, 956 wrong-site incidents were reported to the Joint Commission (the Joint Commission is an organization that reviews and grants accreditation to health care institutions). One study surveyed surgical procedures from 28 hospitals and found the incidence of WSS to be approximately 1 in 112,994 procedures. For the average hospital, this means only one error every five to 10 years.

The Air Force Medical Service has made dental care a focus for processes that work to prevent this type of error. Strategies that you should experience include staff verifying your name and date of birth (also known as "two identifiers") and team members including you in the discussion assessing which tooth or part of your mouth is receiving treatment. You should hear a checklist being used where one person of the team calls out a step in the procedure and the other confirms with a "read back" of the same message confirming steps in the process.


Another high-volume and potentially problem prone process is the prescribing and  dispensing of medications. According to the Institute of Medicine's July 2006 report "Preventing Medication Errors," medication errors harm an estimated 1.5 million Americans each year, resulting in upward of $3.5 billion in extra medical costs.

Our staff uses the two identifier strategy to ensure you are the right person in the office being prescribed the medication and when you pick up the medication you are the right person receiving the medication.

Military facilities use a computer interface between prescriber and pharmacist within the clinic to decrease mistakes from illegible handwriting, dosing errors (20 milligrams vs. 200 grams), and quantity errors (10 suppositories vs. 100 tablets). Allergy alerts are also found in our electronic medical records, and tools to prevent "look alike, sound alike" errors are in place in case you're taking Aciphex for indigestion and shouldn't receive Aricept for Alzheimer's, or cetirizine for allergies vs. sertraline for anxiety.

We also perform a process referred to as medication reconciliation during your appointment to ensure the medications you have at home are the same we have in our medical record, or the medications you are prescribed are the ones you'll be taking home. Keeping a current drug list on your person at all times assists in decreasing these types of errors in prescribing.

Communicating medical results

Communication and follow up of laboratory tests, pathology reports, radiology procedures, and consults to other providers is a challenge to high quality, safe healthcare and is seen in adverse events catalogued as "failure to notify."

Patients with complicated health problems with multiple providers of care are prone to lack of warm hand-offs between well-meaning care givers and may need case managers or disease management assistance from medical home staff.

Processes in the clinic to identify critical test results are created to quickly get the information of an abnormal laboratory value (high blood sugar, out of range blood coagulation study, or positive microbe culture) to the ordering provider to then be communicated to the patient. Patient care teams gather together at specified times of the day in "huddles" to transfer important information that may affect the delivery of your care; medical staffing, availability of lab studies or medications, and prevalence of disease being seen in the community are among the topics that may be discussed.

The implementation of secure, provider-patient email via "MiCare" for two-way, asynchronous communication has also provided a conduit through which the sharing of healthcare information gives you improved access to your provider team beyond the telephone.

Until delivering medical care becomes as simple as accomplishing a meal in your microwave, the challenges of implementing safe, high quality care among so many complex processes will be a challenge. Learning the processes in place to keep you safe, knowing your role as a partner, and communicating to your team will ensure the delivery of healthcare has the best outcome for you and your loved ones.