Josie King was 18 months old in January of 2001 when she was admitted to the hospital after suffering burns from climbing into a hot bath. She healed well and within weeks was scheduled for discharge from the hospital. Two days before she was to return home, she died of severe dehydration and misuse of narcotics.

Ninety-eight thousand Americans die each year due to medical errors according to the Institute of Medicine (IOM). Medical errors are the leading cause of accidental death in America. In the 1999 report by the IOM (Kohn, Corrigan & Donaldson, 2000), To Err is Human: Building a Safer Health System, the estimated cost of medical errors in U.S. hospitals is between 17 and 29 billion - yes, billion - dollars per year. This says nothing of the cost of human lives and trust in the healthcare system. In a new report issued in May of 2009, To Err is Human - To Delay is Deadly (Jewell & McGiffert, 2009), Consumers Union detailed the lack of progress since the 1999 report. There is little evidence to suggest that the number of people dying from medical harm has dropped since the IOM first warned about these deadly mistakes a decade ago," said Lisa McGiffert, Director of Consumer Union's Safe Patient Project (www.SafePatientProject.org).

Four key IOM recommendations were made in the 1999 report. One recommendation was to "Create Accountability through Transparency." This would be done by creating two national reporting systems to help reduce errors: a mandatory and public reporting system designed to encourage accountability, and a voluntary and confidential reporting system to help healthcare providers learn from their mistakes. Progress on reporting since 1999 has been made mostly on voluntary, confidential systems that do not create external pressure for change.

There has been a veil of secrecy surrounding this issue and, according to Kathleen Sebelius, Secretary of the Department of Health and Human Services, "unfortunately, there hasn't been a significant improvement in the level of medical errors, and what is getting worse is hospital based infections that are preventable." The agency for Healthcare Research and Quality, a division of the Department of Health and Human Services, reported in its annual report to Congress that preventable medical injuries are growing each year by one percent. There appear to be three main systemic causes that contribute to this issue:

· Failures in planning (includes assessments, treatments, goals)

· Failure to communicate (patient to staff, staff to staff, staff to physician, etc.)

· Failure to recognize deteriorating patient condition. (2009, IHI.org)

Many patient-advocacy groups are requesting the creation of a federal patient-safety agency as part of the current effort to reform our nation's healthcare system. As of this date, only 20 states plus the District of Columbia require medical error reporting. Pennsylvania is one of them.

What can you do to ensure a safe hospital experience?

· Communicate: Communication is the single most important aid to patient safety. Ask questions and know who is in charge of your care. Seek out your doctors and nurses whenever you are unsure of something.

· Minimize infections: Ask friends and family to stay home if they are ill and ask healthcare providers to wash their hands before and after caring for you. Have soiled linens changed.

· Reduce medication errors: Know your medications and for what they are prescribed. Bring a list of your medications with you to the hospital. Ask your doctor or nurse about any new medications and relay your allergy history or previous reactions you have had to medications, food, etc. Be sure hospital personnel check your identification band before administering medication.

· Falls: Don't be ashamed to ask for help. Most falls occur when patients try to get out of bed on their own. Use your call button to ask for help and wear footwear with non-slip soles. If using a wheelchair, be sure that the brakes are on before transferring into the chair.

· Treatment errors: Ask questions about your diagnosis and treatment. Prior to meeting with your healthcare provider, write down questions you may have. Ask a family member or friend to listen with you when staff explains a diagnosis, test results and treatment. Know that you have the right to ask for a second opinion.

· Other tips: Keep a diary of what happens (who comes in and what they say) and provide information on how to contact your family members or friend who is acting as your primary advocate. Ask if your hospital has a Rapid Response Team.

As we sit down at the tables to discuss the cost of healthcare reform, we cannot continue to ignore this issue of patient safety and accountability. If we want to reduce healthcare costs for all Americans and save lives, healthcare providers and their CEOs must remain diligent in identifying the risk in their own facilities, seek solutions, take responsibility and act to improve processes to reduce the unnecessary deaths that occur in hospitals throughout our nation every day.

On October 23, 2009, Josie's mother, Sorrel King, will be speaking at the Pennsylvania State Nurses Association (PSNA) Annual Summit on A Mother's Journey: Patient-Centered Approaches to Patient Safety. Sorrel, a leading advocate for improving patient safety and co-founder of The Josie King Foundation, states it best in her newly-released book, Josie's Story: "We can start by accepting the fact that there is a problem. We can start by communicating better: listening to patients, listening to parents, and listening to each other."

Join us as Sorrel shares Josie's powerful story and the successes of her Foundation-sponsored safety initiatives. Help us to ensure that what happened to Josie will never happen to another patient. You are invited to DeSales University on October 23, 2009 to learn how you can play a part in patient safety improvements in your community. To register, visit www.panurses.org/summit or contact PSNA at communications@panurses.org.

\\The Pennsylvania State Nurses Association is a non-union, non-profit alternative for professional nursing, representing the over 205,000 practicing nurses in the Commonwealth of Pennsylvania. PSNA works to advance the profession of nursing through education, advocacy, practice and legislation. PSNA is a constituent member of the American Nurses Association and is the official voice for nursing in Pennsylvania. www.panurses.org

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