Patients and relatives alike need to take action to get the best care and prevent hospital medical and medication errors.

You may heave a sigh of relief when you or a relative is admitted to a hospital, because you’re finally getting help for a difficult medical problem. But it’s crucial to remember that what happens in the hospital can sometimes cause additional health problems and that patients and relatives need to exercise caution, ask questions, and be vigilant about the quality of care received.

In the hospital, “You have vulnerable people exposed to powerful medicines and traumatic surgical procedures,” says Robert Wachter, M.D., a professor at the University of California, San Francisco, who prepared a major government report (1) on hospital safety. “And that risk is greater when doctors or nurses are rushed or tired, as they often are, or when hospitals haven’t instituted comprehensive patient-safety practices, as too few have,” Wachter says.

The Institute of Medicine (IOM), which advises the government on health policy, highlighted those dangers in a 1999 study (2) showing that errors made by hospital staff kill up to 100,000 people each year and seriously injure roughly a half-million more. More recent evidence suggests that the problem is either getting worse or is larger than originally thought. A 2004 study (3) of 37 million Medicare patient records suggested that hospital errors killed and hurt roughly twice as many patients as found in the IOM report.

Research has identified four areas of particular concern:

• Infections, including those stemming from antibiotic resistant “superbugs” bred often by the improper and excessive prescribing of antibiotics.
  
• Drug errors, caused by staff forgetting to give a needed medication, giving an unauthorized drug, or giving a drug at the wrong time or in the wrong dose.
  
• Surgical mistakes, including operating on the wrong side of the body and forgetting to remove sponges or clamps before sewing up the patient. Also, patients waking up mid-operation because of insufficient anesthesia.
  
• Miscommunication, which not only makes patients feel helpless but also contributes to drug and test errors, lack of a clear recovery plan, and failure to follow people’s wishes for end-of-life care.
  

In the past five years many hospitals have launched patient-safety initiatives meant to combat those and other problems. Patient and family awareness is another important safety check for heading off problems.

Infection Protection

The Centers for Disease Control and Prevention (CDC) estimates that about 2 million people contract hospital-acquired infections each year, with nearly 90,000 of those proving fatal. Hospitals are filled with patients who come in with infections and others who are very vulnerable due to weakened immunity. Surgical procedures, needles, and catheters can carry germs into the body. And hospital staff may fail to take the necessary steps needed to stop the spread of infection.

The situation has become more dangerous because of the emergence of bacteria that are resistant to antibiotics. Here are some key steps that can help you reduce your risk.

• Insist on clean hands. Some 150 years after scientists demonstrated that hand washing stops the spread of infections, less than half of doctors and nurses adhere to this essential step. Expect anyone who touches you—including your visitors—to first wash his or her hands with soap or an alcohol-based solution. If you don’t see them do that, politely ask if they have.
• Monitor antibiotic use. The overuse of powerful broad-spectrum antibiotics breeds drug-resistant germs that can infect the blood stream and the gut. Stomach infections are particularly common when antibiotics are paired with potent heartburn drugs, which suppress stomach acid and allow invading organisms to thrive. So if your doctor prescribes antibiotics during your hospital stay, especially along with a heartburn drug, ask if it’s really necessary.

Before surgery, on the other hand, antibiotics are sometimes underused or improperly prescribed. While many surgical patients should receive presurgical antibiotics, research suggests that the regimen or the timing of the drug is wrong in up to 50 percent of cases.

Ask your doctor if your operation poses a significant threat of infection; if so, make sure you receive a single dose of an antibiotic in the hour before surgery.

• Stay warm. Body temperature drops by several degrees during surgery, a decline that can impair immune function and blood flow and make infections more likely. So ask your doctor if it makes sense in your case to use a special surgical blanket or other techniques to keep you warm.
  
• Be aware of the catheter. About 40 percent of hospital-acquired infections stem from urinary-tract infections. And the risk of those infections increases significantly if the urinary catheter is left in place for more than two or three days. If you’re still using a catheter 48 hours after surgery, find out whether removal has been overlooked. If you start feeling urinary discomfort, ask your nurse to check whether the catheter is clogged.
  
• Get moving. That can help prevent bedsores, another cause of hospital-acquired infections, as well as potentially dangerous blood clots in the legs. But since postoperative falls are common, ask your nurse—or a friend or relative—to help you out of bed and, if possible, take a stroll. If you must spend a lot of time in bed, ask for special pads that help prevent bedsores and “pneumatic” stockings that can prevent blood clots.
  
• Boost your immunity. Smokers and people with diabetes are especially prone to infection because of weakened immune function. Smokers should give up cigarettes as long as possible before admission. People with diabetes should make sure their blood sugar levels stay under control before and during their hospital stay.
  

Preventing Medication Mix-Ups

The average hospital patient receives 10 different drugs; some of these may have look-alike labels or soundalike names and may be prescribed by various specialists who leave notes in cryptic handwriting or don’t communicate with each other at all. Busy staffers may mistake micrograms for milligrams or mistake one patient for another.

In one study (4) of 36 randomly selected hospitals in Georgia and Colorado, researchers found mistakes in 19 percent of the medication doses given.

The following steps can help prevent medication and test errors.

• Make a drug list. Make sure your attending doctor knows that you want to be told the name of each new medicine given to you as well as its intended purpose. You can refuse any medication you think is being given to you in error. Be certain that any drugs you’ve been taking for chronic conditions, such as diabetes or high blood pressure, are continued, because many hospitals routinely stop such medications when patients are admitted. That practice may increase the risk of complications.
  
• Check your wristband. Make sure the information on your wristband—your name plus any drug allergies—is accurate. Hospital staff are supposed to check the band each time they give you a drug, take a blood sample, or perform a test. If they don’t, it’s wise to mention your name and your allergies.
  

Stopping Surgical Errors

The suggestions listed below may sound like you’re asking for special privileges. But surgeons are getting used to such requests and shouldn’t mind, provided you ask in a friendly manner.

• Pay attention to imaging procedures. It makes no sense for you to have a CT scan of your head if you’re in for a hip replacement. Remind your doctor to tell you about X-rays and scans in advance.
  
• If possible, schedule surgery for well-staffed times. Hospital staffing can be skimpy on weekends and at night. Nonemergency procedures slated for Monday sometimes get delayed or bumped because of the spillover of emergency cases from the weekend; when surgery is done on Friday, you may get reduced postoperative care on the weekend. So ask if you can have your surgery on a Tuesday, Wednesday, or Thursday morning. That way the immediate postoperative hours, when you need the most care, will come on the midweek day shift, when staffing is at full capacity.
  
• Bank your blood. Transfusions pose a very slight risk of transmitting an infectious disease. So if your doctor says a transfusion is likely, consider banking your own blood supply ahead of time.
  
• Ask the surgeon to autograph your surgery site. While reports of surgeons operating on the wrong limb or organ are rare, they occur often enough that hospital-safety experts now advise surgeons to initial the surgery site beforehand.
  
• Know your heart-attack and blood-clot risk. Every surgicalpatient over the age of 50 should be evaluated to see if he or she is at risk of having a heart attack or stroke during the operation. If you are, you should receive a beta-blocker such as metoprolol (Toprol-XL) or atenolol (Tenormin) before the operation and possibly other medications as well.

  And many surgical patients—including nearly all undergoing hip- or knee-replacement procedures—should get blood-thinning drugs, such as warfarin, right after surgery to reduce the chance of getting a blood clot in the leg or lungs.

• Get enough anesthesia. Too much anesthesia increases the risk of complications. But up to 40,000 surgical patients a year wake up in the middle of their operation because of too little. That’s a particular risk to patients undergoing cardiac, obstetric, and major trauma surgeries. Ask your surgeon or anesthesiologist to make sure you stay under for the entire operation.
  

Controlling Your Pain

Roughly half of patients say their pain isn’t adequately managed during their hospital stay. Patients with uncontrolled pain tend to stay in the hospital longer and suffer more complications. Yet drugs and other techniques can substantially ease most pain.

Some surgeons are reluctant to order morphine or other opiates, the strongest painkillers, even though the chance of addiction is minuscule. Or they fail to consider newer options, such as epidural anesthesia, which controls pain by feeding a nerve-blocking drug into the spine. Nerve blockade may be preferable to opiates after certain operations, such as joint replacement, since it controls pain equally well but doesn’t make you groggy. In addition, most hospitals now have patient-controlled intravenous analgesia (PCA), which lets you administer your own medication (while also preventing overdosage) by pushing a button on a computerized pump.

Patients should insist on a pain-management plan. That includes asking your admitting doctor to leave standing orders for pain (as well as insomnia and constipation) medication, so if the need arises you won’t face a long wait while the nurse puts in a call to your doctor. Also ask if the use of PCA is appropriate and, if so, ask to be trained in its use both before and after surgery.

Certain self-help steps may provide further pain control. Several studies have found that surgery patients who listened to soothing music through headphones while recovering reported less pain than other patients. Other helpful relaxation techniques include deep breathing, muscle relaxation, or listening to guided imagery or self-hypnosis tapes.

Clear Communication

Rushed nurses may barely have enough time to answer your call button, let alone give detailed answers to your questions. Technicians take blood samples or wheel you off for imaging tests but can’t always explain what the tests are for. Unfamiliar doctors stop by for brief visits, sometimes with a group of students in tow, and seem to talk about you but not to you. And it’s often unclear who, if anyone, is overseeing all your care.

Here are some steps that can help you communicate clearly with hospital staff.

• Appoint a companion. Having a friend, relative, or private-duty nurse with you is particularly important the first night after surgery and at other times when you may be too sick to fend for yourself. A companion can help you assert your needs and preferences, articulate your questions, record the answers, retain copies of key medical documents, including your drug list, and advocate for you if any problems arise.
  
• Be polite but assertive when necessary. Complaining too often or too aggressively about minor inconveniences can alienate the often-overworked staff. But you should expect reasonable and timely responses to reasonable requests and questions. If you’re being neglected, ask to speak to the hospital’s patient advocate or social-service worker.
  
• Find out who is in charge. To minimize the chance of conflicting orders from specialists, have one doctor coordinate your treatment. Your primary doctor or one of his or her colleagues should visit you daily. Alternatively, your care can be coordinated by a staff hospitalist, a new breed of specialist who focuses on overseeing the care patients receive while in the hospital.
  
• Prepare a living will. Make sure your admitting doctor and the hospital have a copy of your living will and health-care proxy form. This written record of your preferences can help you avoid overaggressive care. Appoint a health-care proxy to make sure doctors follow your wishes and to make decisions not covered in your living will if you’re incapacitated.
  
• Plan your discharge. At discharge time, ask your doctor, surgeon, or discharge planner for a list and instructions for the medications or devices you may need at home. Next, discuss how to prepare your home for your convalescence. For example, you may want to move to a downstairs bedroom, get an elevated toilet seat, move obstructing furniture out of the way, and remove throw rugs.
  

Finally, find out whether you’re likely to need physical therapy, home nursing care, or a stay in a rehabilitation facility. Once you check into the hospital, ask to speak with the hospital’s discharge planner (and ask your doctors to do the same), so the hospital can start arranging for the appropriate services.

If the hospital tries to discharge you before you feel ready, insist on talking first with your doctor. You shouldn’t go home if you feel disoriented, faint, or unsteady, have pain that’s not controlled by oral medication, can’t go to the bathroom unassisted, or can’t keep food or drink down. If your doctor isn’t able to extend your stay, appeal to the discharge planner or the patient advocate. If necessary, contact your insurance carrier and the hospital administration. And ask a companion to take you home and stay there with you for at least a day.

What You Can Do

To optimize a hospital stay:

• Enlist the help of people who can help monitor your care, including a friend or relative, your primary-care doctor, and, if necessary, the hospital’s patient advocate or social-service worker.
• Talk with your doctor about the drugs and tests you’ll likely need while in the hospital and about your living will.
• Ask your surgeon about the optimal timing for surgery, antibiotics, transfusions, anesthesia, staying warm during the operation, and also pain control.
• Check all medications and ask for an explanation if any are unfamiliar.
• If necessary, remind the nurses and doctors to wash their hands, check your wristband, catheter, and surgical site, assess your risk of complications during surgery, and get you up walking again.
• Object strenuously to attempts at premature discharge and get complete information about convalescing at home.

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CITATIONS

Wachter RM, et al. “Making health care safer: A critical analysis of patient safety practices,” Evidence Report/Technology Assessment no. 43, Agency for Healthcare Research and Quality, July 2001.

Institute of Medicine. “To err is human: Building a safer health system,” National Academy Press, Washington D.C., 1999.

“Health Grades quality study: Patient safety in American hospitals,” Health Grades, inc., Lakewood Colorado, July 2004.

Barker, KN, et al. “Medication errors observed in 36 health care facilities,” Archives of Internal Medicine, September 9, 2002, pp. 1897-1903.

OTHER SOURCES

Dial S, et al. “Risk of clostridium difficile diarrhea in hospital in-patients prescribed proton pump inhibitors: Cohort and case-control studies,” Canadian Medical Association Journal, July 6, 2004, pp. 33-8.

Burke, JP. “Infection-control, a problem for patient safety,” New England Journal of Medicine, February 13, 2003, pp. 651-6.

Royston, D, Cox, F. “Anaesthesia: The patient’s point of view,” The Lancet, November 15, 2003, pp. 1648-58.

Dimick, JB, et al. “Hospital teaching status and outcomes of complex surgical procedures in the United States,” Archives of Surgery, February 2004, pp. 137-41.

Pittet, D. et al. “Hand hygiene among physicians: Performance, beliefs, and perceptions,” Annals of Internal Medicine, July 6, 2004, pp. 1-8.

Noble, DW, Kehlet, H. “Risks of interrupting drug treatment before surgery,” British Medical Journal, September 23, 2000, pp. 719-20.