___________________________________________ Medical Errors and the United States Healthcare System
Pressure Ulcers: Although most hospital-acquired pressure ulcers area reasonably preventable, approximately 2.5 million Americans develop a pressure ulcer in US acute care facilities every year [47]. These injuries can result in extensive harm, including chronic wounds, and as many as 60,000 deaths annually [47]. Hospital-acquired pressure ulcers are responsible for a huge financial burden. According to a recent estimate, based on 2016 dollars, the national burden of hospital-acquired pres- sure ulcers could exceed $26.8 billion. The cost of treatment was estimated to be approximately $10,708 per person [47]. Approximately 59% of the costs associated with these ulcers are attributable to a small number of patients with stage 3 and 4 full-thickness wounds [47]. There are a number of factors that increase risk for pressure ulcers[48] , [49]: • Advanced age: An elderly person’s skin has less subcutaneous fat, which leads to decreased protection from pressure. • Friction/Shear: Decreases the epidermal layer, reducing protection of the skin. • Hypotension: Increases the response of local tissues, making skin more vulnerable to breakdown. • Immobility: Lack of mobility can lead to sustained pressure on bony prominences. • Length of stay in critical care units: Longer stays are indicative of more critical conditions. Such conditions are generally associated with decreased mobility and position change and increased shear force, all of which increase the risk for skin breakdown. • Length of time on mechanical ventilation: Indicates inadequate oxygenation and the need to provide ventilation mechanically. Decreased oxygen levels mean decreased oxygen to body tissues, including the skin. • Moisture: Moisture (e.g., incontinence, sweat, failure to dry skin after bathing) contributes to skin breakdown. • Nutrition: Inadequate nutrition alters the proper state of the skin, contributing to skin breakdown. • Pressure: The longer pressure is sustained, the more likely is local tissue ischemia, edema, and tissue death. • Pressure scale risk scores: The higher the score on a pressure scale score, the greater the risk of pressure ulcer development. • Vasoactive medications: Vasoactive medications given to improve blood pressure increase vasoconstriction. This may decrease perfusion of skin tissue.
Venous Thromboembolism (VTE): VTE includes both deep vein thrombosis (DVT) and pulmonary embolism (PE). According to the CDC, VTE is a leading preventable cause of hospital death [50]. VTE may affect as many as 900,000 people each year in the US, and be responsible for between 60,000 and 100,000 deaths [50]. Approximately 5% to 8% of the US population has one of several genetic risk factors, known as inherited thrombophilias in which a genetic defect can be identified that increases the risk for thrombosis [50]. Risk factors for VTE include[51] • Birth control pills or hormone therapy. • Blood-clotting disorders. • Some malignancies. • Increasing age. • Overweight or obese.
• Personal or family history of DVT or PE. • Pregnancy and the postpartum period. • Smoking. • Vein disease(s).
Strategies for the prevention of DVT include[51] , [52] • Administrating anticoagulant therapy as indicated. • Promoting early movement and physical therapy. • Facilitating position change in patients who have difficulty moving themselves. • Applying compression stockings or pneumatic compression devices as ordered and indicated. • Teaching patients and families about the importance of early movement and position change. CASE STUDY John L Smith is admitted to a midsize urban hospital for ambulatory left knee replacement on the same day that John R Smith is admitted for ambulatory left hip replacement. Both surgeries were scheduled to be performed by the same orthopedic surgeon and surgical team. The same admitting nurse performs the verification and reconciliation process in the preoperative area and the patients wait to be called for surgery. The surgeon’s first surgery ran late so his entire surgical schedule was delayed for the day. Once his first surgery was completed, he left the ambulatory surgery area to perform emergency surgery on an accident victim. The admitting nurse informs James R Smith that his surgery needs to be rescheduled. When the orthopedic surgeon arrives back to the ambulatory surgery area, John L Smith has been prepped for left hip surgery by the surgical team and the surgery proceeds. It is only after the surgery that the team realized that the surgical site was never marked, the wrong chart traveled with the patient to the operating room, and in the rush to perform the surgery, no verification process was undertaken in the operating room.
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