The Face of Patient Safety

Kelly StephensHuman error is not Just a serious problem in health care. Just last month in Pakistan, a three-train wreck, believed to have been caused by human error, resulted in the death of 133 people, according to a CNN news report.

Reportedly, the driver of one of the trains misinterpreted a signal and rear-ended another passenger train that was stopped at the station. A third train then slammed into the three carriages that were thrust onto an adjacent track during the initial collision.

One hundred and thirty-three dead—nearly two and a half times the number killed in the July 7 London transportation system bombings—and at least 135 seriously injured, all because of negligence.

What a waste.

But how can operator errors be prevented?

This issue of 24×7 delves into the possibilities. As discussed in the article on incident investigations (page 20), hospitals can rely on clinical and biomedical engineering departments to lead internal inquiries into what caused equipment to fail or malfunction. Then, organizations such as the Food and Drug Administration track trends across hospitals and work with manufacturers to engineer products that are less prone to operator error.

In the article on clinical trials and comparative evaluations (page 30), clinical and biomedical engineering departments help ensure that when hospitals make major purchasing decisions, they buy the equipment that is least likely to be misused.

Incident investigations, clinical trials, and comparative evaluations all take extra time and resources, but as you will read in these articles, in many cases, they prove to be worthwhile.

But even with what seems like a fool-proof system in place, errors still occur. Last month, the Joint Commission on Accreditation of Healthcare Organizations reported that “despite repeated warnings and extensive labeling requirements and standards,” some cancer patients undergoing chemotherapy were still being accidentally injected with a powerful cancer-fighting drug, called vincristine, in an incorrect way, resulting in death or permanent paralysis.

It seems that health care providers are, after all, only human—and that the job of safety watchdog is never done.

To represent more accurately the work you do to ensure patient safety, Art Director Mark Strassner has revamped 24×7’s logo. You’re constantly on the move working with some of the most sophisticated, complex devices available, and we hope our new, more technologically advanced, look reflects just that.

c01_sig.gif (2601 bytes)