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Patient Safety Requires High Index of Suspicion For Errors

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To improve patient safety, doctors, nurses and all healthcare personnel must have a high index of suspicion for errors, reports a recent Medication Safety Alert in the Institute for Safe Medication Practices. Each person on the team must anticipate and investigate the possibility when any member of the healthcare team, regardless of experience or rank, expresses concern about possible errors or when patients are not responding to treatment as expected. Often the discovery of an error is begun when someone asks a question just because something doesn't seem right. Unfortunately, there is a hierarchy of rank amongst healthcare professionals that creates a culture where even the slightest questions about possible problems with patient care are not treated seriously and dismissed without any follow up. Outright intimidation and disrespect of medical subordinates are rare, but over-deference to "more experienced" providers is common. Subordinate staff who do speak up are easily convinced that their concerns are unfounded. As a result, opportunities to catch errors before harm occurs are lost.

A pharmacist assures a nurse that the strength of a drug is correct when questioned about the total daily dose. A nurse reassures a patient that the medication is correct when told by the patient that the pills "look different." A physician convinces a pharmacist that the prescribed dose is correct even when questioned because it differs from a protocol. These examples show how healthcare providers who question patient care are all too easily convinced that others know more than them, when in fact an error is occurring.

It is logical to defer to people with more expertise. However, this causes the person voicing the question to be easily convinced that their concern is unfounded, while at the same time the person being asked the question does not recognize the voiced concern as a potential threat to the patient safety. Suspicion is suspecting that something is wrong without proof, on very slight evidence and sometimes even just on a sense of uneasiness. A low index of suspicion for errors is dangerous in a healthcare system that already is reluctant to acknowledge medical errors. A high index of suspicion is necessary to improve patient safety, and every member of the team should consider a potential medical error as a possibility when a concern is raised. All concerns should be taken seriously.

Superficial responses to patient care questions that should raise concern about possible medication errors are:

The attending told me to order it that way.

The patient says that's how he takes it at home.

This is a special case.

The patient is on a protocol (without providing the protocol).

That's the way the dose is written in the progress notes.

It's on the list of medications the patient gave me.

We always give it that way.

All healthcare practitioners need to encourage staff to ask questions and be receptive to expressed concerns. Deference to expertise can lead to complacency and medical errors that are otherwise preventable.

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