Sometimes there are links between small individual errors, sometimes the failure of individuals or certain control mechanisms - treatment errors in the medical field are common. Thanks to an initiative of the Alliance for Patient Safety, openness comes into the discussion.
Open handling of treatment errors
A classic case: During the night shift, a nurse monitored a patient whose upper airway had to be regularly aspirated after a total gynecological operation and tracheotomy. The station was hectic and many patients needed help. "When changing the infusion bottle, I have to fixate the indwelling cannula again with the gynecological patient, other patients ring and shout, I get infected by the hustle and forget the prepared fixation plaster ...".
A mistake: The patient "... lies lifeless and blue-marbled in bed, the bell had slipped out of reach." She had pulled the cut fixation plaster from the IV pole over the cannula, which is in the trachea, and is suffocated. " (from: Aktionsbündnis Patientensicherheit eV: Learning from mistakes, p. 8).
17 authors report on their professional treatment mistakes in the booklet Learning from mistakes . Chairperson of the Patient Safety Alliance, Matthias Schrappe, who published the booklet in early 2008, called for an open approach to the so-called malpractice: "Only if we talk about mistakes can we prevent them."
Even Schrappe himself admits mistakes. As a junior medical assistant, he did not immediately realize that a patient with heartbeat and agitation suffered from a pulmonary embolism. His boss was not interested in the near miss at the time. For example, patient safety has become an important issue for the AOK, co-editor of the booklet Learning From Mistakes .
With more than 17 million treatments a year in German hospitals, it claims up to 1.7 million patients who have become victims of adverse events. Nevertheless, patient safety has usually become a public issue only when, for example, the wrong leg has been amputated.
What is a treatment error?
According to the patient safety alliance, around 17, 000 people die every year in Germany as a result of avoidable errors in hospital treatment. Every thousandth hospital patient is affected by it - in most cases it is infections due to poor hygiene and side effects of medicines.
An error in treatment is defined as an inappropriate, for example, inaccurate, incorrect, or inaccurate treatment by a doctor and may affect all areas of medical activity, including doing or not. In this case, the error may be of a purely medical nature, relate to organizational issues, or it may be errors of downstream or zuarbeitender persons such as nurses and nurses.
Missing or incorrect, incomprehensible or incomplete information about medical interventions and their risks also count as treatment errors. According to the Medical Service of the Health Insurance Funds (MDK), around 40, 000 patients complain every year because they believe they have been harmed by a treatment error.