Fusion Newsletter Article: Marty’s Corner – Medical Errors Still Topping the List

Marty’s Corner: Medical Errors Still Topping the List

In this column, as well as in all our marketing materials, we speak frequently about patient safety. Lest you think it’s too frequently, just look at the recent report in BMJ (formerly the British Medical Journal): Medical/hospital errors are the third leading cause of deaths – higher than respiratory disease, accidents, and stroke. In presentations on informatics that I give to dietetic students or at state dietetic association meetings, I always have a slide on the landmark 1999 Institute of Medicine report entitled, To Err is Human: Building a Safer Health System1. To many, this report, which revealed the staggering incidence of patients being harmed or even losing their lives due to medical errors, was the start of the effort to move from paper to electronic health records. It helped lead to the creation of the Office of the National Coordinator for Health Information Technology (ONC), charged with "coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information."

Medical Errors Still Topping the ListMoving from paper to electronic health records (EHRs) is a huge, expensive effort, but achieving interoperability, where systems such as electronic health record companies communicate with each other (like our bank ATMs have done for years), is proving to be a daunting task. Nevertheless, there have been great strides in implementing EHRs throughout the USA, certainly incentivized by the Centers for Medicare and Medicaid Services’ Meaningful Use requirements and their accompanying financial benefits and penalties. Despite all this progress, I must admit I was surprised yet not surprised, therefore, to hear about the BMJ report. It was truly a wake-up call that our work is far from over.

In food and nutrition services departments, hospital foodservice software automation can do its part in helping to ensure patient safety. Recent developments such as wristband scanning at the time of tray delivery, not only to correctly identify the patient but also to ensure that his/her diet order is still accurate, can help prevent situations such as a patient who is NPO receiving and unknowingly consuming a meal. (This happened to one of my colleague’s fathers, resulting in an additional nine days in the hospital). Certainly, software systems can prevent patients from being able to select and receive foods to which they are allergic. Real-time interfaces between EHRs and these systems can ensure that the patient’s diet order is always accurate. Helping prevent harm to patients, and certainly to reduce the staggering number of patient deaths, is a charge for all hospital departments and personnel, and one that can be assisted by each department ensuring that their contact with patients always puts patient safety first.

  1. https://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf

Marty Yadrick, MBI, MS, RDN, FANDArticle by: Marty Yadrick, MBI, MS, RDN, FAND - Director of Nutrition Informatics and former President of the Academy of Nutrition and Dietetics; Fusion, 3rd Quarter, 2016