Military Officer - July 2006 - (Page 63) PROBLEM 3 Wrong-site surgery This is perhaps the most horrifying and dramatic kind of medical mistake: A patient wakes up after surgery to find that the wrong limb has been operated on or the wrong procedure has been performed. Wrong-site surgery en“Sign Your Site” campaign, remindcompasses all surgical procedures ing surgeons to mark the surgical performed on the wrong patient, site with their initials before making wrong body part, wrong side of the the first incision. In 2004, the Joint body, or at the wrong level of the Commission made surgical site correctly identified anatomic site. marking mandatory for all accreditAs of December 2005, 455 wronged hospitals and surgery centers. site surgeries had been reported to What you can do: Ask your the Joint Commission on Accredita- surgeon to mark the surgical site tion of Healthcare Organizations, before you are sedated or anesthea nonprofit agency that evaluates tized so you can ensure it’s in the and accredits health care facilities. correct place. Also, ask if the surgiWhat’s being done: Studies cal team routinely takes a “time show that most wrong-site surgeries out” just before the surgery begins. occur in orthopedic cases, and orDuring a time out, the team takes thopedic surgeons were the first a few critical moments to assure group to formally tackle this issue. themselves that they are performIn 1998 the American Academy of ing the correct procedure at the Orthopedic Surgeons created the correct site on the correct person. PROBLEM 4 Health careassociated infections PROBLEM You might correlate the antiseptic smell of doctors’ offices or hospitals with cleanliness, but the truth is, health care facilities are breeding grounds for infectious diseases such as pneumonia, hepatitis, and tuberculosis, which can be passed between health care workers and patients. These infections, which are called health care-associated infections, affect approximately 2 million people and cause 90,000 deaths annually, according to the Centers for Disease Control (CDC). What’s being done: The CDC has numerous guidelines for protecting patients from health care-associated infections, including specific instructions for managing surgical incisions, ventilators, catheters, and other procedures and devices that make patients vulnerable to infection. What you can do: Many health care-associated infections are transmitted from patient to patient through a seemingly innocuous source: the hands of health care workers. Make sure that every medical professional who touches you cleans his or her hands first by washing them or using a hand-sanitizer gel. Medication errors According to the AHRQ, 7,000 people die each year from taking the wrong kind or dosage of medication or taking it in the wrong way. Adverse medication reactions are responsible for more than 4 million doctor visits every year, according to a 2005 AHRQ study. Many of these incidents could be prevented if patients knew more about the medicines they take and how and when to take them. [CONTINUES ON PAGE 75] J U LY 2 0 0 6 5 MILITARY OFFICER 65
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