CHANGES UNDERWAY
St. Luke's officials said hospital staff already have instituted several policy changes to help prevent similar problems from happening again. After a death from a medication error, for example, St. Luke's adopted a hospital-wide policy of bar coding patient's wrist bands for specific medications, bar coding the actual medication and bar coding the medication record that's read by nurses.
To help prevent falls, which accounted for one death at St. Luke's, all new hospital beds are being ordered with alarms.
``You can't take the human element out of it, but we can try to make sure there's as little room for mistakes as possible,'' Hoag said.
St. Mary's already has conducted a thorough investigation and review of the patient death related to a fall. Since then, a new policy has been developed, and efforts to prevent falls have been redoubled. That includes assessing every patient on every shift for their vulnerability to falls. If a patient is considered a candidate for a fall, they are given a bright pink wrist band, and a bright pink alert poster is placed above their bed.
``We can't stop falls, but we can try to cut down their number and the severity,'' Renier said. Since the fatality, ``we've made reducing falls a top priority.''
The 99 serious problems reported Wednesday compares with just 9 reported problems at all of the state's hospitals in 2002, before the new law passed. In the past, hospitals were required to report problems only with so-called vulnerable patients.
Before the new law, complaints of hospital mistakes filed by the general public to the state outnumbered hospital reports 6-to-1.
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