04-16-2010 03:29 PM
Another sad story of a pediatric overdose of heparin has come out of Nebraska recently:
While reading this, my first thought was "Why did this happen again?" I had trouble believing that this occurred again after all the publicity with Dennis Quaid's twins and the fourteen infants in Corpus Christi. It is no secret that there is a large risk of patient harm with anticoagulation therapy. In fact, the Joint Commission identified National Patient Safety Goal 3E in 2008 to "Reduce the risk of harm associated with the use of anticoagulation therapy." Since his twins survived the heparin overdose, Dennis Quaid has joined the efforts to raise patient safety awareness on the issue including an appearance on Oprah.
I realize it is too early to jump to conclusions. A lot of investigation needs to happen to understand what went wrong in Nebraska. I also realize that patient harm from an error are a result of a systemic issue. But how can an error that has been so publicized in the last few years continue to occur? Why is the healthcare community not learning from it's mistakes?
I am in the middle of reading the book "Why Hospitals Should Fly" by John Nance. Nance touches on the topic of collective intelligence - which is the shared intelligence that occurs from the collaboration and sharing of ideas. One of the reasons the airline industry has gotten safer over the years is the shared intelligence of solutions after a crash or event occurs. When hundreds of lives are on the line, one airline shouldn't have the solution and leave the others in the dark. His point is this sort of collaboration needs to occur across different hospitals so the collective intelligence of healthcare as a whole can learn from medical errors and protect patients against it happening again.
What needs to happen in order for hospitals to share their findings with each other to avoid an incident like this from happening again? Is Nance asking for too much? Until the root causes of this particular incident are uncovered, we won't know for sure if this was due to a similar cause behind the previous events. But I can't help but wonder if this could have been prevented.