List of medical errors leading to patient harm

(Also check 'Patient Identification Policy and Procedure)

Medication related

1.       Administration of wrong medicine

2.       Administration of medicine to a wrong person

3.       Administration of wrong dose of medicine

4.       Administration of medicine through wrong route

5.       Administration of medicine at wrong time

6.       Administration of medicine with wrong rate of administration

7.       Administration of expired medicine

Features of a disabled friendly hospital

A disabled friendly hospital is one which enables people with disabilities to freely and safely move and access facilities within the hospital. Such hospital building provides an environment of independence to individuals with disability, which is their right granted under Persons with disability act, 2016. Patient with a disability is considered as a vulnerable patient and hospitals are required to take care of their safety. Being disabled friendly uplifts the image of a hospital and is also expected by various accreditation agencies.

So what are those features that makes a hospital, ‘disabled friendly’? Well, such hospital building typically accounts for the need of two kinds of disabilities, i.e. loco-motor disability and visual disability. People with loco-motor disability will either be on wheelchair or crutches and which requires a disabled friendly hospital to make its interior easily accessible for wheelchair. People with limited vision will need mechanism to understand ways and areas within the hospital. This is typically achieved by strategically placing tactile floor (guiding block) and using braille, which the visually disabled person can sense.

Here is a list of features that goes into making of a disabled friendly hospital.

Taking Care of Vulnerable Patients

Vulnerable patients are those patients who, for any reason, are not able to protect or take care of himself/herself, against exploitation or harm. Such patients are prone to various risks within the hospital, such as fall, injury, neglect, abuse, medical errors and acquiring of infections. Vulnerability of a patient may be due to his/her age, physical or mental condition. It is the duty of the hospital to identify such patients and provide them with necessary support so that they are safe in the hospital surroundings.

Following type of patients can be identified as vulnerable

      1.       Patients who are old (above 65 or a certain age, as decided by the hospital)

      2.       Patients who are of minor age (Patients below 12 years or as decided by the hospital)

      3.       Patients with physical problems, such as limited mobility, blindness, deafness, speech limitations etc.

      4.       Patients with mental problems, such as depression, mental retardation, forgetfulness etc.

      5.       Patients who are unconscious or in semi-conscious stage

      6.       Patients who are illiterate and have difficulty in understanding written instructions

Infection control care bundles

Care bundles is an effective way of preventing healthcare associated bundles (HAI) amongst high risk patients. A ‘bundle’ is a set of practices that, when performed collectively, reliably and continuously, have been proven to improve patient outcomes. While there are care bundles for various clinical care processes, it is very popularly used in prevention of HAIs. Care bundles for preventing common HAIs are given below (Reference – WHO and CDC guidelines)

Criteria for transfer of patients from OT recovery area

Post-surgery patients are kept in recovery area till they recover from the effect of Anaesthesia and become fit to be transferred to intermediate care (ward/room). In recovery area, the patient is under observation of Anaesthesiologist and his/her physiological parameters are being monitored. While transferring the patient out of recovery, it is critical to ascertain that the patient is in a right physiological condition and it is safe to shift him/her to ward/room. To ascertain this, appropriate criteria must be applied to assess the patient’s condition.

The criteria that can be used for this purpose are described below. Aldrete method can be used to score these criteria and base the decision on total score.

1.       Consciousness level – Ability of patient to respond to verbal instructions and answer the questions. Patient should be oriented to their surroundings. They should be able to cough, when asked.

Passive Euthanasia in India and Making Advance Medical Directives: Details that hospitals and patients must know

Passive Euthanasia has been legal in India since 2011 after Supreme Court issued its judgement in Aruna Shanbaug’s case. Although the plea of the petitioner, Journalist Pinki Virani, was rejected, supreme court gave directives on when and how passive euthanasia can be allowed and executed in Shanbaug’s case, making passive euthanasia as legal in India.

A case on similar line, filed by an NGO ‘Common Cause’ was also going on whose plea was to make it legal for people to make Advance Directive for passive euthanasia. On March 9, 2018 Supreme Court of India upholds passive euthanasia and issued regulations for executing Advance Directive for passive Euthanasia.  The regulation passed through this judgement will remain binding across the country till the time, Parliament of India comes up with a bill or law on this subject.

The hospitals and medical fraternity (specially those that provide end-of-life care) need to make themselves aware about the legally correct way of handling advance medical directives for passive euthanasia. This post explains the legal directives in simple language for its correct implementation. The information presented here is derived directly from the 538-page official judgement report of the Supreme Court of India.
(Check - Advance Medical Directive Form for Passive Euthanasia)

      1.   What is Euthanasia and what is India’s legal stand on it?

Fulfilling patients’ rights in hospital

Patients and their family has certain defined rights which hospitals and medical practitioners need to fulfill. Some of these rights are legally enforceable and a patient can approach consumer court or higher court, if those rights are infringed. Other rights are derived on ethical ground and can affect the image of healthcare provider and its relationship with patient community. Besides legalities, almost all healthcare accreditation programmes gives a lot of importance to protection of patients’ rights and not fulfilling the same may lead to denial of accreditation. While it is important for healthcare providers to fulfill the rights of patients, some of these rights are complex to understand because of the unique and complex scenarios that occurs in healthcare frequently.

This post attempts at simplifying those rights with respects to its scope and intent and guide the healthcare providers on what needs to be done to fulfill them. The rights discussed here have been referred from charter of patients’ rights by consumer guidance society of India, code of ethics regulation by MCI and NABH accreditation standards.

    

Code blue system in hospitals

Code blue is perhaps the most popular codes used in hospital for managing emergency situation. Code blue is a code given to identify and communicate that a medical emergency, of the nature of cardiac arrest, has occurred and the patient needs to be attended immediately for life saving measures. (Other codes - Code Pink, Code Red). Since it deals with the life threatening situation, swift and coordinated action by a team of professionals is of paramount importance. This calls for designing and implementing a highly efficient system, which can work in round the clock and can cover entire hospital. This posts elaborate on all considerations that should be made while designing a code blue system. Also check code blue form and crash cart checklist along-with this post.

Crash Cart policy and checklist in hospital

Crash cart is a lifesaving trolley which contains essential medicines, instruments and equipment that can be used to save life of a patient (or a person), in case of medical emergency such as heart attack. In hospital there is always a risk of a patient undergoing cardiac arrest and hence it is important to have crash cart trolleys stationed at appropriate places for the code blue team to use it on the patient, whenever required. (Code blue team is a dedicated trained team of doctors and nurses, who can perform basic and advanced life support function on patient who has undergone a cardiac arrest).

In-order to ensure that crash cart is usable whenever required some policies and practices needs to be put into place. It is also important that crash cart contains all things that may be required during a medical emergency. The checklist below can be used for this purpose.

Checklist of items in crash cart (Source: UC DAVIS Health System, Centre for professional Practices of Nursing)

General Consent and Informed Consent in Hospitals

General consent is an umbrella consent taken for conducting those patient care processes which do not pose any significant risk of harm to patient. For example, physical examination, collection of blood sample, Intravenous administration of fluids etc. are less risky processes when compared to surgery, anaesthesia etc. and can be done by taking a general consent from patient. The reason it is called as a general consent is because under one consent, the hospital can do multiple patient care processes that are within the scope of general consent. Even though it is called as general consent, it has to be informed to the patient about the scope its scope, before he/she gives consent.

In OPD patients, general consent can be considered as implied for all non-risky OPD based procedures and written consent may not be required. However, in patients being admitted, general consent must be documented with patients’ signature. A standard general consent form can be used for this purpose. The scope can cover consent for…

·    Admitting the patients in an intermediate care ward/room (Scope does not cover admission of patient to ICU for which a separate informed consent should be taken)

Nutritional Screening and Nutritional Assessment in Hospitalized patients

Nutritional screening is the first and rather quick evaluation of a patient’s nutritional condition. The end result of nutritional screening is to find if there is any indication for detailed nutritional assessment and possibly a nutritional intervention. Nutritional assessment is an in-depth evaluation of a patient to identify and quantify specific nutritional needs and intervention. The end result of nutritional assessment is a nutritional plan which is based upon specific nutritional problems of the patient.

Nutritional screening should be done for all patients admitted in hospital and nutritional assessment is done only for indicated patients. This is mandated by many regulatory and accreditation authority across the world including NABH of India. While nutritional screening can be done either by a dietician, a doctor or a nurse, detailed nutritional assessment should be done by a qualified dietician.

There are research evidences that nutritional needs, if not addressed, adversely affect the treatment outcome of patient. Hence, a hospital that is committed to provide good quality healthcare, must include nutritional screening and nutritional assessment as an integral part of their clinical practices. This is also an accreditation requirement. 

Following important points must be ensured for nutritional screening and assessment.

List of adverse anaesthesia events

Following is the list of adverse anaesthesia events, which must be reported and analysed to determine appropriate corrective and preventive action

·     Cough, hiccups, chopping on induction        

 ·     Inappropriate patient movement during recovery

·         Low BP, SpO2

·         Residual neuro-muscular block in recovery

·         ET tube inserted in right main bronchus

·         Slow to regain consciousness in recovery

·         Anaesthetic turned off too early in operation

·         Cardiac arrest after induction

·         Asystole, Bradycardia following induction

·         Postoperative fits in epileptic patients

·         Difficult intubation

How Pharmacist can improve quality care in hospitals

By - Pallvit Jain, Student of PGDM-Healthcare Management at Goa Institute of Management

Consider the following statement:

Doctor to Patient, “Take Omeprazole 20mg on empty stomach every day for 5days”

Would you consider this statement enough for giving direction of dosage to patient?

Now consider another statement:

“Take the tablet omeprazole 20mg empty stomach, every day for next 5days. Have meal only after 20min of dosage”.

How much does it cost to run a hospital?

Hospitals are places that operates 24 x 7 x 365. Crowded OPDs, long waiting time, queued up counters etc. are things that are considered a normal routine of any typical hospital. Many may wonder that the promoters of hospitals must be making big bucks out of this never slowing down business. While it’s true that hospitals generate big revenues from patients’ bills, they also spend a handsome amount on its operational expenses. The cost of running a hospital can be really high and fluctuating and can sometime result in financial losses instead of any gain. The cost at which hospitals operate leaves very thin margin and it is absolutely important that the business managers keep an eye on the expenses, or else the margin may vanish. Below, after going through the expense data of few large hospitals, I have listed down what are the important cost components and how much do they affect the overall expenses in a hospital.

(Read - Performance measures for hospital business)

CASE STUDY – Implementation of cost cutting measures in hospital by a CEO

(This case study is related to cost management in hospital and is based on approach used by CEO to implement certain cost cutting measures in his hospital.)

Situational background

The CEO of a large hospital has been particularly concerned about increasing operational cost of the hospital and have decided to initiate some cost containment measures. As a process he put a 3 member group to work out recommendations to control operational cost. The group after thorough review came out with several recommendations. The CEO after going through various recommendations and using his own judgement decided to go ahead with 3 recommendations in first place. CEO being a believer of inclusive decision making decided to discuss it with key people in his organization.

CASE STUDY - Cross referencing of patients between specialities

(This case study is on the complexity of operational process in patient care, and is based on challenges in managing cross referencing of patients between specialities.)

Situational background

A large and busy multi-speciality hospital is organized in various clinical departments and each department has divided its OPD days, emergency duties and surgery days (if applicable) between their team of consultants. As per its policy each admitted patients should be visited by the consultant in-charge at-least once in a day. Sometimes a patient admitted under a consultant may require a cross reference from a consultant of another speciality. In this situation, the process is that the consultant in-charge writes the orders for a cross reference from required speciality in patient’s record. The duty doctor then fills up a cross-reference form with necessary clinical details of the patient and send it to the HOD of respective department. The HOD then allocates it to one of their consultant, who should attend the patient and provide his opinion by documenting it in the patient’s record. 

However, frequently there are problems that is being encountered by doctors, nurses and even patients which are as described below.

Understanding waiting time from perspective of patient’s psychology

Waiting time is an interesting phenomenon in healthcare. On one hand longer waiting time to meet a doctor can cause discontentment, very low or no waiting can rouse suspicion about the credibility of doctor. There is always a psychological aspect to waiting time, which most hospital manager seems to miss. Waiting time in hospitals are seen in direct link with customers’ satisfaction or dissatisfaction (check patient satisfaction feedback form), but to be better able to manage waiting time, we also need to understand how are they linked. 

Communicating bad news to patient and family

When you are the first person to know that a patient has a terminally ill disease and is likely to die soon, how do you communicate this to the patient or his/her family members? This is one daunting task which many doctors face on a very frequent basis. This is not just a piece of information, but an information that is going to severely affect the emotions of receiver and can have an adverse effect on their psychological status if not given with due care. And yet, there is hardly any formal training that doctors receive on how to break a bad news. 

My post on ‘Dealingwith relatives in case of patient’s death’, identifies the need of communicating the bad news in a proper way with patient and family members. Here I going to write about what should be the proper way, which is based upon an article published in ‘The Oncologist’ on ‘A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer’. Although the article is specially for dealing with unfavourable news in case of cancer patient, the protocol it outlines is relevant for any other bad situation. 

Before this I suggest you to read the post on ‘Dealing with relatives in case of patient’s death’, to appreciate why is this issue so important.

The six step protocol for breaking bad news is

Dealing with relatives in case of patient’s death

Patients’ deaths are a routine thing in most hospitals, especially those catering to critically ill patients. But for patient’s relative it could be the only event and they may have very strong sentiments towards it. There could be a sea difference in the way a patient’s death is taken by hospital in comparison to his/her relatives. This difference, at times, become a reason for dissatisfaction, blame and even litigation on hospital by relatives

In my study on online reviews of different hospitals, posted by patients and their relatives, I found that significantly high number of negative reviews and low ratings were given by those whose patients died in a hospital. The reviews largely blamed hospital/doctor for death of their patients and alleged them with negligence and incompetency.  

(For detailed on this studyplease read article  on ‘Avoiding poor online rating of your hospital')

How not to prepare for accreditation

With a sizable number of accredited and a long list of applicant hospitals, NABH accreditation is on its way to soon become a norm for hospital industry in India. Almost all for profit hospitals and a large number of charitable hospitals in India aspires for accreditation and most of them have either revamped or in process of revamping their organization in accordance to accreditation standards.


I have written a long post on 'How to prepare for accreditation', but equally important is also to know, how not to prepare for it. Below, I have covered this topic explaining what could happen if wrong approach is followed for accreditation preparation.