VI Musabaka 2010

[AshLu]

VI Musabaka 2010

Final Report

Culture and Science Academy

Mentor

Dr.Mohammed Osama

Team Members

Osama Ragab Ahmed

Maher Mohammed Ragai

Ahmed Osama Baker

Executive Summary  

An alarming statistic from an American healthcare organization is that an average Of 95’000 people in the USA died in hospitals in each of the years 2005, 2006 and 2007, As a result of potentially preventable, in-hospital medical errors. Asserts that “the problem is not bad people in healthcare–it is that good people are Working in bad systems that need to be made safer” ,Many health professionals are concerned about the growing number of patients who are misidentified before, during or after medical treatment.

Indeed, patient identification error may lead to improper dosage of medication to patient, as well as having invasive procedure done. Other related patient identification errors could lead to inaccurate lab work and ,results reported for the wrong person, having effects such as misdiagnoses and serious medication errors ,wrong blood type transferring, new born mix-up or abductions , missed warning  from the medical equipment  .

For example like emergencies, large numbers of patients can arrive at hospital accident and emergency departments at the same time. In the confusion, paramedics’ records of their injuries and of treatment received at the accident site and in transit, can be illegible, damaged or lost. Delays can result, and some patients can even get the wrong treatment.

RFID technologies have proven to be ideal for identifying and locating things because they increase the reading accuracy and visibility of tagged items far beyond bar codes and other labels. The results can include greater efficiency for automating inventory processes, finding misplaced items, and generally keeping better track of things as they move through their life-cycles.

Radio Frequency Identification (RFID) is a method for remotely storing and retrieving data using devices called RFID tags or transponders. An RFID tag is a small object, such as an adhesive sticker, that can be attached to or incorporated into a surface. RFID tags are composed of an antenna connected to an electronic chip. These chips transform the energy of radio-frequency queries from an RFID reader or transceiver to respond by sending back information they enclose.

Finally, a computer hosting a specific RFID application or middleware pilots the reader and processes the data it sends. RFID has great characteristics:

1.       It is possible to scan tags in motion.

2.       Since radio waves can pass through most solid objects, the tags don’t need to be in direct line of sight of the RFID reader.

Problem Analysis

Much has been written about medical errors since late 1999 when the Institute of Medicine (IOM) published its

watershed report, To Err is Human: Building a Better Health System. The well-publicized results of this study faulted America’s health system for causing between 44,000 and 98,000 error-related deaths annually and called for improvements in the reporting and handling of medical errors. Though some have taken issue with the report’s data on deaths attributable to errors, it exposed the fact that serious, preventable errors are occurring in our health system.

Primary care avoided the harsh glare of the IOM report, which focused almost exclusively on the inpatient setting,

largely due to the fact that there are insufficient data to quantify the impact of medical mistakes in Hospitals. Hospitals have the perfect opportunity to look at the IOM report as a call to action to examine care processes and take steps to reduce the incidence of errors in their practices.

There is a well-established body of research about errors in medicine, and most experts agree on the following:

1. Errors will happen. Since no human is infallible, errors are bound to happen, and this includes physicians and their

staffs working in the delivery of health care services.

2. Since errors can be expected, systems must be designed to prevent and absorb them.

3. Errors are not synonymous with negligence. Medicine’s ethos of infallibility leads, wrongly, to a culture that sees

mistakes as an individual problem and remedies them with blame and punishment instead of looking for root causes

and fixing problems by improving systems.

4. Creating a culture supportive of errors reporting is the starting point in reducing future medical errors.

While errors are a part of every day practice, many errors are the direct result of overly complex processes and are

preventable. As Becher and Chassin write, "If each step in a ten-step process can be performed with 99 percent

reliability, that system functions error-free 90 percent of the time. A similar process with fifty steps functions error-free only 61 percent of the time."(1) They illustrate this point by describing a breast cancer patient who travels through the health care system to seven or more locations for diagnosis, treatment

ATTACHMENT: ORIGINAL REPORT