Roughly one week ago, we examined five medical errors that shaped the standard of care. From advances in trauma response to improvements in prenatal care, the medical landscape has seen a variety of needed changes. Today, we take a look at five more mistakes that revolutionized patient care.
6. Fatal Allergies – Allergies were sometimes overlooked in the 1990’s. There was a case where a young child named Betty was given penicillin, had a severe reaction, and was rushed to a hospital. Years later she was given penicillin to combat a strep throat and had a fatal reaction. In 1999, the Institute of Medicine brought allergy awareness to prominence in a detailed report. Out of the report grew a new standard of care that included making the allergy reaction selection a mandatory entry in medical order-entry systems, and adding written and verbal prompts to ask for any known medical allergies.
7. Potassium Mishaps – Potassium levels can drop for many women during pregnancy. Before potassium management came under scrutiny, there were reports of women overdosing after receiving too much potassium. In the 1980’s and 1990’s, the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) and other groups drew attention to the mishaps and asked for the removal of concentrated potassium chloride vials from patient care areas. Today, almost all US hospitals have removed the drug from floor stock and potassium is now added to IV’s by the manufacturer and is labeled. Limiting access to concentrated amounts of potassium has led to a significant drop in fatal errors.
8. Pressure Ulcers – Pressure ulcers often develop in patients who can’t move their body without help. If a patient is not moved regularly they can develop pressure ulcers, and if those ulcers become infected, amputation is sometimes required. Each year more than 2.5 million people in the US develop pressure ulcers, and bedsores can be fatal. Over the years hospitals have mandated checks for patients who have been in bed for a certain duration. This includes turning the patient to a new position every two hours, and changing sheets to keep them dry.
9. Lifting techniques – Lifting techniques have been around for centuries, but there wasn’t a lot of focus on teaching nurses or therapists how to handle heavy weights or awkward positions. After an incident where a nurse and patient suffered broken bones after falling, the American Nurses Association decided to review lifting techniques. The ANA supports policies that eliminate manual lifting, and has pushed for safe patient-handling techniques involving full-body slings, assistance lifts, and lateral transfer devices.
10. Mammograms – Mammogram technology was developed in the 1950’s and became the norm in the 1960’s. Its implementation was instrumental in early detection of breast cancer. In 2005, about 68% of all US women between the ages of 40 and 64 years of age had a mammography in the previous two years. All US states except for Utah require private health insurance companies and Medicare to pay for breast cancer tests.
Dr. Silverman comments
In reference to bedsores, these types of pressure ulcers are completely preventable. Technology in bed manufacturing has added increased support beneath bony prominences, and although these beds are expensive they can save money in the long run and allow patients to sleep more comfortably.
Related source: Medscape.com
