by Jengy Pie

Created on: December 06, 2008   Last Updated: December 16, 2008

A hospital is a place of healing and recovery, where one person takes care of another. Doctors, nurses, physiotherapists and many allied health workers work as part of a multidisciplinary team with the one goal of promoting patients to their optimum physical, psychological and social health. Unfortunately all of these people are human, and to be human is to make mistakes. There are many systems in place to compensate for human error, such as highly trained stuff, multiple checking systems and environmental safety measures. These only make errors less likely, not impossible. In reality some doctors are overworked and tired, people may shortcut checking protocols and sometimes there is just insufficient knowledge and experience. Errors are always to the detriment of the patient. Some of the potential errors are discussed below.

Medications are a common source of error. Mistakes may arise through drug dosing or class selection, resulting in overdosing or potential adverse drug reactions. The greater the number of drugs prescribed the more likely errors will occur, particularly when there are four or more medications. Dosing errors may result from poor doctor training or experience, failure to take into individual patient factors, such as liver and kidney function, or improper administration and monitoring by nursing staff. The selection of the inappropriate class of drug may make side effects more common, such as sedation and unsteady gait. Also, patient allergies may not be taken into account and the results may be catastrophic. Depending on the medication, the adverse outcomes may include liver or kidney damage, excessive sedation or postural dizziness leading to falls, allergic reactions leading to airway compromise and potential death, and the list goes on.

Errors with patient management on the ward can also cause unnecessary harm. If intravenous drip sites are not reviewed regularly for signs of infection then microbes may enter the bloodstream and cause widespread illness, or attach to heart valves causing infective endocartiditis, a condition with a high mortality even with treatment. If urinary catheters are inadequately sterilized and monitored, urinary tract infection (UTI) may result, a potentially devastating outcome for the elderly patients. UTI may lead to renal impairment and delirium, which significantly increases patient mortality. If deep vein thrombosis (DVT) prophylaxis measures are not regularly practiced, such as ankle exercises, stockings

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