"An error doesnt become a mistake until you refuse to correct it.
Canadian-American chemist and author O.A. Battista once said, “An error doesn’t become a mistake until you refuse to correct it.” In the medical community, errors have soaked up millions of dollars and compromised patient care, and many of these errors are potentially preventable. In addition, the government in recent years has begun to hold payment for such errors.

This week, a report from consulting firm Milliman showed that 1.5 million medical errors occurred in 2008 alone. These errors leave the U.S. with a $19.5 billion tab and lead to 2,500 excess patient deaths. The most common medical error was medical device complications, which accounted for 30,973 errors in 2008, costing almost $1.1 billion.

In related news, researchers from the University of California, San Francisco, advised that more of an emphasis needs to be placed on improving overall quality process measures.

Results of the study showed that only 12 percent of patients undergoing CABG received optimal care where all quality process measurements—antimicrobial use/discontinuation, serial compression device use and statin administration—were employed. Nearly half of patients missed three or more of these quality measures. Researchers determined that the best way to cost and care improvement is by focusing on all quality metrics, not just one at a time.

In parallel, a study this week in JAMA showed that the number of patients who obtained MRSA, the most common hospital-acquired infection, decreased by 9.4 percent per year between 2005 and 2008.

This decrease equated to an estimated 28 percent decrease in all hospital-onset of invasive MRSA infections and a 17 percent decrease in all invasive healthcare-associated community-onset infections.

Lastly, the FDA and researchers from York Hospital have warned that use of Bard Peripheral Vascular’s Recovery and G2 vena cava filters may be linked to adverse events due to their potential to fragment and embolize in the body. While the FDA has not banned the devices use, the agency warned that physicians should exhibit caution and remove the filters as soon as applicable, as most of them are meant for short-term use to decrease the risk of pulmonary embolism.

In September 2005, the Bard Recovery's design was modified after reports that it fragmented into patients bodies after implantation. The second-generation Bard G2 filter, however, still is problematic, fragmenting in 16 percent of patients and embolizing in 25 percent of patients in the study.

While technological advances and a focus on quality process measures have helped to improve patient care, a better focus needs to be placed on systematic management of preventable errors in order to deliver the most optimal care.

On these topics, or others, please feel free to contact me.

Kaitlyn Dmyterko
Staff Writer