National Patient Safety Foundation

Creating communications bridges between departments is vital to avoiding breakdowns in infection protocol.
by Nanne Finis, RN, MS

The often-quoted phrase “First, Do No Harm” is not really in the modern Hippocratic Oath. But a recent study of medical errors in U.S. hospitals suggests that perhaps it should be widely adopted as the first commandment of health care.

That study estimates the true number of deaths due to preventable errors may be four times more than the 98,000 per year quoted by the Institute of Medicine in its report To Err Is Human.

A culture of safety?
Given the mission of health care institutions, the general public might be surprised to hear the rising chorus of health professionals calling for a “culture of safety” to be adopted in our nation’s hospitals. Yet a 2012 IOM study reported that one-third of all hospital patients experience some form of hospital acquired conditions (HACs), ranging from minor injuries to death.

Infection, for example, was historically considered an acceptable risk of providing care, but recent changes in reimbursement regulations mandated reductions in medical errors and penalized re-admissions and infection-related length of stay. Now a whole range of technologies is available to contain the spread of infection, from robots that blast germ-killing ultraviolet light to remote monitors that keep track of hand hygiene compliance by health care workers.

But problems persist. The Joint Commission, which accredits more than 75% of U.S. hospitals, found infection prevention and control deficiencies in about half of the hospitals it surveyed in the first half of 2014. Although one in 25 hospital patients will acquire an infection during treatment, more than a third of U.S. hospitals that responded to a recent survey reported they do not have a certified infection prevention specialist on staff.

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