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Safeguards to Reduce Fatal Medical Mistakes Announced

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TIMES STAFF WRITER

Hospital leaders on Tuesday announced a nationwide campaign to reduce the number of fatal mistakes made by medical personnel--including steps such as putting an “X” on a patient’s body where a surgeon is supposed to cut and using special colored labels on bottles of lethal drugs.

President Clinton also ordered the federal health programs that cover senior citizens, the poor and the military to use the latest techniques available to avoid errors.

The wave of attention to medical error comes one week after an Institute of Medicine report found that preventable mistakes kill 44,000 to 98,000 people a year and add $17 billion to $29 billion to the nation’s health bill.

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But the issue “is about far more than dollars or statistics, it’s about the toll that such errors take on people’s lives and on their faith in our health care system,” Clinton said.

The president ordered the 300 private health plans covering federal workers to seek ways to improve patient safety, and he promised to ask Congress next year for additional research funds to find techniques to reduce the frequency of medical mistakes.

He also directed government-run health plans--Medicare for senior citizens; Medicaid for the poor; and the Defense Department and the Department of Veterans Affairs for active and retired military personnel and their families--to adopt methods to reduce errors by doctors, nurses and pharmacists.

No Punishment

Clinton was joined Tuesday in his call for medical safety by Dick Davidson, president of the American Hospital Assn., who said that personnel would be more willing to report mistakes if they were assured that they would not be punished--or sued.

This approach is used successfully in the airline industry, where pilots are not punished if they report near collisions within 48 hours, said Gordon M. Sprenger, president of the Allina Health System, based in Minneapolis.

Manufacturing firms also successfully record their near-mistakes to devise better working procedures.

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In the hospital industry, major incidents--such as a patient’s severe illness or death because of a medical mistake--are formally reported. But it is the much more numerous mistakes that are caught just in time that could lead to systemic improvements, ultimately reducing the frequency of illness and death, Sprenger and Davidson said.

For example, some drugs have very similar labels, making potentially deadly mistakes possible when a rushed nurse or doctor grabs a bottle from the shelf. Sprenger said his hospitals now store the lethal drugs in bins. And he said he is going to ask manufacturers to consider different colored labels for certain types of drugs.

Signs for Patients

In some rooms, a sign is placed above the patient’s bed, reading: “This patient is not ambulatory.” That tells the nurse or attendant or technician coming into the room that the person shouldn’t get out of bed to go to the bathroom without assistance, Sprenger noted.

Hospital surgery teams now meet beforehand, he said, to review a long checklist of tasks and to make clear what each person in the operating room will do.

“It is going to take all of us working together to continue to improve the safety of our medical system,” Davidson said.

The hospital group will work with a research organization, the Institute for Safe Medication Practices, which reviews medical errors, to develop a list of successful procedures, Davidson said. Doctors, nurses and other health care professionals can report actual and potential errors with medication by calling 800-23-ERROR.

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Meanwhile, Sen. Edward M. Kennedy (D-Mass.) said he will work with members of the Republican majority in Congress a create a “National Center for Patient Safety.”

Kennedy said he was “amazed and enormously distressed” by the Institute of Medicine report.

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