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The Patient Safety Digest

Reflections on Patient Safety Awareness Week

Every year there is one week set on the calendar that we look forward to recognizing all year long: Patient Safety Awareness Week. Established by The Institute for Healthcare Improvement, the goal of Patient Safety Awareness Week is simple: raise awareness of patient safety risks in healthcare. 

According to the World Health Organization, an estimated 134 million adverse events occur each year due to unsafe care in low- and middle-income countries, resulting in approximately 2.6 million deaths. 

But, what about the U.S., which arguably has one of the most advanced healthcare systems in the world? Studies show that medication safety issues in the U.S. result in more than 1.5 million patients harmed and hundreds of thousands of deaths annually. Additional research posit that up to 400,000 deaths occur in the U.S. each year due to medical errors or preventable harm, with almost a quarter of those deaths directly attributed to medication-based errors. Moreover, adverse drug events (ADEs) result in more than 770,000 injuries or deaths in U.S. hospitals each year. 

Beyond these errors, opioid medication abuse and its consequences has become an even greater patient safety crisis. With over 2.1 million patients addicted to opioids in the U.S., we are now in a place in which a patient is more likely to die from an accidental opioid overdose than from a car accident.

These numbers are staggering. One week each year is simply not enough to drive the systemic changes required. This is a challenge I confront on a daily basis as a physician, educator, patient safety researcher, and in my role as CEO of MedAware.

Understanding Points of Risk Along the Patient Care Journey

The patient care journey usually begins with a patient coming to their clinician with a problem. The first step the clinician must take is determining a diagnosis. The doctor will then set out a treatment plan, work to execute that plan, monitor the treatment and adjust as the situation changes. With each treatment adjustment, the doctor will monitor and change the treatment course if needed. This cycle is repeated throughout the patient’s journey, whether a condition evolves over time or entirely new issues develop.

Throughout this cycle, there are constant vulnerabilities to a patient’s safety. 

  1. Diagnosis: a doctor could reach the wrong conclusion, resulting in misdiagnosis and maltreatment.

  2. Developing a treatment plan: even with the right diagnosis, the treatment also needs to be guideline based, up to date and personalized for the patient’s personal profile and unique needs.

  3. Treatment and monitoring: once a patient begins treatment, new situations may evolve that could render their current medication regimen as dangerous, trigger an adverse drug event to occur, and cause a shift or deterioration in the patient’s condition.  

The first step to preventing patient harm throughout the patient’s journey is understanding where the pitfalls exist throughout the patient’s treatment journey—from the moment the patient engages in an encounter with a clinician (either in person or via telehealth).

The key to safe and effective disease management is establishing trust and creating dialogue with patients so they fully engage in the process. This starts understanding their diagnosis and what their treatment plan is, to the potential risks to look out for and ensuring that the patient knows how to follow up with their doctor with any questions or diagnostic testing along the treatment journey. 

Unfortunately, this is an ideal and not the de-facto approach to the patient journey. This is why it is also critical to consider clinician-driven “smart” technologies—like artificial intelligence (AI)—to support with the heavy-lifting and provide peace of mind by way of a safety net that’s there just in case it’s needed. This is our constant, daily focus at MedAware. By combining these two approaches of advanced technology and improved patient-physician dialogue, we can learn how to mitigate risks and ultimately improve patient safety throughout the care pathway.

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