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Checklists, Communication by Health Providers Improve Patient Safety

Anyone beset by illness understands the worry and pain it brings. Understandably, an ill person’s primary focus is to get better, and he or she hopes and trusts that a hospital stay, medication or other health care will make him or her well. Occasionally, otherwise preventable actions by health care providers can make an illness worse. The health care field has been struggling to reduce medical errors for decades, and now research and strategy aimed at putting a stop to medical mistakes are beginning to show promise.


Something as simple as a checklist can be used to avert injury and illness. Surprisingly, a common cause of infection in hospitals occurs because of the failure of health care workers to wash their hands as much as needed. According to the Centers for Disease Control and Prevention (CDC), 2 million patients become infected in hospitals each year. Infections are the fourth-leading cause of death in America and the cost an estimated $40 billion a year to the health care system.

The New York Times recently reported on an experiment conducted by the New England Journal of Medicine that prevented infection in central line catheters, which is a life-threatening infection that can be avoided by thorough hand washing. When a Michigan hospital used a simple checklist available to all health care workers involved in the procedure, which included a hand washing step, in three months the median infection rate was reduced to zero percent. Since that result, many hospitals have created similar checklists to lower the rate of medical mistakes.


Part of the above solution in reducing infection involved communication. Anyone, including doctors, nurses and other hospital staff, were encouraged and empowered to speak if anyone on the team missed a step. A lack of communication in health care can lead to devastating injury.

Another striking example where a lack of communication resulted in catastrophic injury occurred to a patient visiting an ophthalmologist. The ophthalmologist recommended the patient undergo cataract surgery. During the visit the patient informed the ophthalmologist’s office that there was a possibility of a blood clotting disorder. The ophthalmologist advised the patient that if that was the case, due to the possibility of uncontrolled bleeding cataract surgery could result in blindness. To be sure, the ophthalmologist sent the patient to his primary care doctor for diagnosis.

The primary care doctor then ran tests and received results that showed the patient did, in fact, have a blood clotting disorder. However, the patient never heard from the primary care doctor and so scheduled the surgery. The surgery resulted in blindness.

This tragedy could have been avoided by any of the following communications:

  • The primary care physician could have indicated the test results to the patient
  • The primary care physician could have communicated the test results to the ophthalmologist
  • The ophthalmologist could have told the primary physician why the test was needed
  • The ophthalmologist could have asked the primary physician about the test results

How common are preventable errors such as the example above? Unfortunately, medical mistakes are more likely than many think. The Institute of Medicine estimated as many as 98,000 people die every year from medical mistakes. That is more people than die of diabetes and Alzheimer’s disease. In fact, that would make it the sixth leading cause of death in the United States, according to statistics by the CDC. Even more become severely injured – up to 181,000 in a single year, according to the Congressional Budget Office.

Get Help for Recovery

While improving patient safety by lowering medical errors is an important goal of the health care field, mistakes still happen – sometimes with tragic results. If you have been injured through medical error, you may be able to get help with medical bills and other costs. Contact an experienced medical malpractice lawyer who can discuss with you whether you have a case.