How Medicine Has Learned From Its Errors

Medication Errors

Patients, families of patients, and even physicians have suffered throughout the years when critical mistakes have been made. However medicine has transformed thanks to these mistakes; now we continue to benefit from the standardization of medicine.

Some of the major transformations of medicine have come at the costly expense of others lives. In 1976 an orthopedic surgeon and his family were in a plane crash. The care received by his family at a local hospital was inadequate but their trauma and the medical mistakes made after their ordeal led to Advanced Trauma Life Support (ATLS) which essentially changed the standard of care in the first hour after trauma. The doctor involved in the plane crash helped produce the first ATLS course and by 1980 the American College of Surgeons Committee had adopted ATLS and offered the course worldwide.

In the early 1980’s ABC’s 20/20 ran a special on how anesthesia kills or causes brain damage to thousands each year. Following the program, the American Society of Anesthesiologists standardized anesthesia care and patient monitoring. Those standard practices, in place today, include the use of pulse oximetry and end-tidal carbon dioxide monitoring for anesthetized patients. Newer standardized practices have reduced the number of anesthesia-related deaths to 1 in 200,000 per year as opposed to 1 in 10,000 in years past.

Another standard was implemented after two parents found their newborn daughter was born with severe brain injury and cerebral palsy following administration of oxytocin to speed up labor during childbirth. The addition of oxytocin led to fetal distress, which the obstetrician was unaware of at the time. Now fetal monitoring testing uterine contractions and fetal heat rate is the standard of care. Fetal heart rate monitoring allows the physicians to follow the status of the fetus during labor in case there is fetal distress, which would be reflected by the monitor. Now experts suggest that every woman should be monitored using electronic fetal monitoring and the monitor should be reviewed frequently by the nurse or physician.

While many mistakes have led to a heightened standard of care some mistakes by physicians have led to only small improvements in the standard of care. The Joint Commission for Accreditation of Healthcare Organizations (JCAHO) established protocols mandating standardization of preoperative procedures to verify correct surgery is performed on the correct patient at the correct site. Wrong-site surgery was happening all to frequently and JCAHO made preventing wrong site surgeries a goal. However even with today’s technology and protocols wrong-site surgery occurs at the alarming rate of 40 times a week nationwide, according to a JCAHO survey.

While the medical field continues to learn from its mistakes in order to improve care provided to patients, there is most definitely room for growth, as with any field. Bringing these errors to the attention of physicians, hospitals and other healthcare organizations is important in order to continue improving the standards of care in place today.

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