Preventing infections and other problems for hospital patients is a big job. A new pilot program will use both technology and family help in the effort. The Johns Hopkins University program will cost $9 million. Doctors and nurses know many ways to help to keep patients safe. The new project will use automatic signals and controls to make sure they are carried out. For example, breathing problems can be a side effect of some painkillers. The Johns Hopkins program will link the machines that dispense medicines and keep track of breathing. Painkillers will be cut off automatically if breathing problems occur. The hospital also wants to put a checklist of daily care tasks on a tablet computer in each patient's room. Hospital staff will urge family members to check the tablet and speak up if something is missed. For example, raising the head of the bed can help to prevent pneumonia for some patients. So can brushing their teeth. The Hopkins project is funded by the Gordon and Betty Moore Foundation. It's the first step in a planned $500 million foundation program to improve patient care. The Associated Press wrote about the new programs August 28.

By Howard LeWine, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

American medicine used to keep mum on the subject of medical mistakes and the harm they do. Harvard researchers helped break that silence with a 1990 study of "adverse events" in hospitals throughout New York State. Then the Institute of Medicine (IOM) put its spotlight on the issue with a 1999 report, "To Err Is Human. "

The IOM estimated that as many as 98,000 Americans may die from medical mistakes each year. That's more than the number who die from breast cancer and traffic accidents combined.

The institute noted that medical practice and technology had become very complicated. For example, doctors and nurses needed to keep track of every medicine each patient was taking, every drug allergy and all possible harmful interactions between drugs. They could not be expected to remember all of those details about all of their patients. Instead, the institute argued, health-care organizations should aggressively invest in systems that avert mistakes.

What has been done during the last 13 years? A lot, but not enough.

Much of the focus has been on preventing medicine mistakes. This is the biggest cause of preventable medical injuries and deaths. In hospitals, more than half of medicine errors occur when a drug is being ordered. The doctor forgets that the patient is allergic to the drug, the dose is wrong, or the pharmacist can't read the doctor's handwriting. Computerized drug ordering has greatly decreased order errors.

Mistakes also can occur when nurses dispense drugs to patients. Bar-code systems can prevent many errors. The nurse scans the bar codes on the medicine and on the patient's wristband. The match is double-checked against data in the hospital-pharmacy computer.

But hospitals remain unsafe environments even with improvements in technology. A major reason is the rising number of infections that don't respond to the usual antibiotics. Even with more and more attention to avoiding spread, the antibiotic-resistant germs keep finding ways to get stronger.

In part, the rise in drug resistance is a credit to advances in medicine that allow people with lasting illnesses to live longer. These patients almost always have impaired immune systems. They can't stop germs from taking hold in their bodies once they are exposed.

Hospitals have made strides to improve safety. But the processes are too often not coordinated or systematic. Johns Hopkins is employing engineering principles to thoroughly evaluate new ways to make hospitals safer. Family involvement is at the center of this new program.

Johns Hopkins, like most hospitals, recognizes the majority of the problems. But the hospitals have not been able to fix them consistently.

What Changes Can I Make Now?

The most important change for you or a loved one is to ask what you can do and look out for to help ensure safety. Engage the nurse. He or she will be with the patient all day or all night.

Talk with the nurse soon after admission to the hospital. This way it won't seem like you are challenging the care delivered. More and more doctors and nurses realize that involved patients and families help to decrease errors and prevent further health problems.

Here is a checklist of standard questions for all patients in hospitals:

• What medicines are currently ordered?
• Is the patient receiving blood clot prevention? People in the hospital are at increased risk of blood clots forming in the legs. Medicines, mechanical devices on the legs, or both can help to prevent clots.
• Can any of the tubes, such as intravenous lines and catheters to drain urine, be removed today? Keeping the number of tubes going into the body to a minimum helps to decrease infection risk.
• Does the patient need to be kept in a certain position in bed? For example, raising the upper body may help with breathing or help avoid the backup of stomach contents into the lungs (aspiration).
• Can I help get the patient out of bed? This question prompts everyone to work with the patient to get him or her moving.
• What should I do about hand cleansing? (And feel free to make sure that all visitors have washed their hands before touching the patient.)
• What should I do now to be prepared for discharge?

You will have other specific questions and concerns. Express them, and always finish with "How can I help?"

What Can I Expect Looking to the Future?

The hospital doesn't have to be a scary, dangerous place. In the near future, the checklist to help maintain safety will become automated. Meanwhile, you and your family can help to make the hospital stay a safe one by getting engaged.