AFT: Publications: American Teacher: May/June 2003: Preventing medical errors

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American Teacher
May/June 2003--Special Report

Preventing medical errors
AFT and NEA team up to address troubling healthcare issue

When 17-year-old Jesica Santillan died Feb. 22 after receiving transplanted organs of the wrong blood type, her death made headlines across the country. But the same day, with little or no publicity, about 250 other people also died in U.S. hospitals as the result of medical errors--mistakes which, like the one that killed Santillan, could have been prevented.

Between 44,000 and 98,000 people die each year because of medical errors during hospitalization, according to a 1999 report from the Institute of Medicine of the National Academy of Sciences. Even at the bottom of that range, the report noted, those numbers make medical errors the nation's eighth leading cause of death, slightly ahead of car accidents.

The report outlined a number of relatively simple improvements that could dramatically cut the error rate. "It would be irresponsible to expect anything less than a 50 percent reduction in errors over five years," the report noted.

That was more than three years ago. Has anything changed? "We've seen pockets of dramatic improvement," says Donald Berwick, president and CEO of the Institute for Healthcare Improvement and one of the report's authors. "Some of the hospitals we work with have had 10-fold reductions in adverse drug events. But overall, we're a long way from the goal. We're still building the will for change, and we're working to alter some deeply ingrained behaviors and attitudes in the healthcare system."

Fighting medical errors is one of the projects of the neAft Partnership Joint Council. The NEA and AFT are members of the Leapfrog Group, a coalition of more than 130 public and private organizations that sponsor healthcare benefit plans. The group focuses on three reforms that could reduce the death toll by more than 50 percent--or about 100 lives a day:

Get doctors to stop scribbling prescriptions on slips of paper and start using computers equipped with error prevention software that flags those which may contain mistakes.
Refer patients who need certain complex procedures to hospitals that offer the best chance of survival.
Staff intensive care units with doctors who have credentials in critical care medicine.

How can NEA and AFT affect hospital policies? One way is through collective bargaining. The unions have sponsored two conferences this year to teach union negotiators about medical errors and the Leapfrog reforms. The negotiators can then push school districts to use the Leapfrog ideas as criteria for choosing healthcare providers for school employees.

In Wisconsin, WEA Trust, a nonprofit organization created by the NEA-affiliated Wisconsin Education Association Council to provide insurance and other services for school employees, joined a local Leapfrog group that has started publishing hospital safety data on the Web. "That was quite controversial at first," says WEA Trust executive director Al Jacobs. "The hospitals were not happy." Jacobs concedes that the statistics are far from perfect as measures of hospital quality, but he says a University of Oregon study showed that hospitals whose data are published make greater efforts to improve.

"Very often the frontline healthcare professionals are blamed for these medical errors. But changing the system is what is needed to reduce the number of errors," says Candice Owley, chair of the AFT's healthcare division.

This article, the third in a series on healthcare issues and how they affect educators, is a project of the neAft Partnership. A primary aim of the partnership is to keep members of both unions informed about joint programs and activities in areas of common concern. NEA staff writer Alain Jehlen wrote this article, which also appears in the May issue of NEA Today.

School nurses stretched thin

A public school may not be as dangerous as a hospital intensive care unit, but medical errors can happen there, too. In a survey of more than 600 school nurses conducted by University of Iowa professor Ann Marie McCarthy, half of the nurses reported medical errors at their schools during the past year. Although most errors were missed doses, there also were significant numbers of overdoses and wrong medications.

The National Association of School Nurses recommends that there be one nurse for every 750 students, but McCarthy reported that the actual student/nurse ratio is almost twice that.

Meanwhile, "inclusion" has brought more students who need sophisticated medical support into the schools.

McCarthy's survey found that more than 5 percent of students take some kind of medication, and 75 percent of medications are given to students by someone other than a school nurse.

That can be dangerous, says Carolyn Seifert, a registered nurse at Lake Silver Elementary School in Orlando, Fla, and and a member of the Florida Education Association, a joint NEA-AFT state affiliate. Two years ago, she noticed something strange about a medicine tablet she was about to give a third-grader. It didn't look right--and it wasn't. The child's mother had put her husband's powerful heart medication in the boy's bottle by mistake. Giving a small child an adult dose of the heart drug could have stopped his heart, says Seifert. And someone with less training might not have noticed. According to the University of Iowa survey, errors were three times more likely when someone other than a nurse administered the medication.

"Sometimes," says Seifert, "a para doesn't want to give out medication because she's fearful of making a mistake, but the principal says, 'Do it.' The principal may not like it, either, but he knows the parents want the medication to be given in school." The solution, she says, would be to hire more school nurses, but with budget cuts and new mandates to raise test scores, she doesn't see that happening soon.

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