when medical folk make mistakes

In the last few years there has been a lot of talk about medical errors in the media. Figures were released sighting from 50-100,000 deaths occuring very year in this country from these errors. When I first heard the figure I was stunned. Wow. I thought, it couldn't be right. Then I felt defensive. A kind of "hey we do the best we can" feeling. Sometimes it does seem like the media delights in making headline news out of medical mistakes.
So at work yesterday one of the docs was talking about Dennis Quaid appearing on 60 minutes last Sunday, talking about the medication error that endangered his newborn twins. He spoke of the unbelievable fact that he and his wife were not notified until the next day about the error. They had called the hospital that night and were told everything was fine. They were met the day they learned of the error by hospital management and hospital risk management (legal dept). I get the feeling that the hospital was more worried about being sued or saving face then providing the parents with information. But I wasn't there....There is no doubt that there has been a code of silence in the hospitals about making errors, especially if the error would have no dire consequences. A kind of "what they don't know won't hurt them" mentality. I've seen this in the years I have practiced.
It's really hard to admit fault, to admit you made a mistake to someone who is the subject of your mistake. When you make a mistake as a nurse, there is a sense of panic that overtakes you. An "OH MY GOD!!" feeling. There is a tremendous guilt associated with error in medicine. So naturally people want to avoid having to tell the patient. It's scary. Nurses feel a lot of sympathy for other nurses who make big mistakes that lead to harm or death. We know that "there but for the grace of Go go I"....We realize that in the stressful, harried environment of the hospital that could have been us.
An interesting aspect of this particular case is that this same thing happened in Indiana a year or two earlier, where a 3 babies received the wrong dose of heparin (blood thinner) had died. One of the factors in the error was the similarity of vials both the same size, same color printing. So the company redesigned the vials. But meanwhile the old similar vials were not recalled to prevent further errors. They were left in hospital stocks and continued to be used. Quaid pointed out that we recall bad meat in this country, but medication that has caused death is not recalled. Interesting point.
Humans are not perfect, everybody knows that. We make mistakes. We will continue to make mistakes. Especially as the environment of the hospital grows more stressful, there is less staff. But there really is no excuse for implementing systems that will greatly decrease the likelihood of error. The VA put such a system into place a couple of years ago. The patient has a ID band applied with a bar code. A hand held device scans the bar code and apparently tells whether or not this medication has been ordered for the patient. Whether this would work in an environment like the emergency department where we give medications sometimes quickly and only get a verbal order is questionable...
Something has got to be done. All these errors are unacceptable to everyone. The current way of doing things is not working. Every nurse learns when giving medication the following: Five Rights, namely, right medication, dose, patient, time, and route. It's basic nursing 101 stuff but it doesn't always prevent error.
This is an opportunity for technology to be used for a good end. Of course technology costs money....where does that come from? That's the question...