Medical error
Encyclopedia
A medical error may be defined as a preventable adverse effect
of care, whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment
of a disease
, injury
, syndrome
, behavior
, infection
, or other ailment.
However, medical error definitions are subject to debate, as there are many types of medical error from minor to major, and causality is often poorly determined.
report estimated that medical errors are estimated to result in about between 44,000 and 98,000 preventable deaths and 1,000,000 excess injuries each year in U.S. hospitals.
Some researchers questioned the accuracy of the IOM study, criticizing the statistical handling of measurement errors in the report and reporting both significant subjectivity in determining which deaths were "avoidable" or due to medical error and an erroneous assumption that 100% of patients would have survived if optimal care had been provided. A 2001 study in the Journal of the American Medical Association
of seven Department of Veterans Affairs
medical centers estimated that for roughly every 10,000 patients admitted to the subject hospitals, one patient died who would have lived for three months or more in good cognitive health had "optimal" care been provided.
A 2006 follow-up to the IOM study found that medication errors are among the most common medical mistakes, harming at least 1.5 million people every year. According to the study, 400,000 preventable drug-related injuries occur each year in hospitals, 800,000 in long-term care settings, and roughly 530,000 among Medicare recipients in outpatient clinics. The report stated that these are likely to be conservative estimates. In 2000 alone, the extra medical costs incurred by preventable drug related injuries approximated $887 millionand the study looked only at injuries sustained by Medicare recipients, a subset of clinic visitors. None of these figures take into account lost wages and productivity or other costs.
According to a 2002 Agency for Healthcare Research and Quality
report, about 7,000 people were estimated to die each year from medication errors - about 16 percent more deaths than the number attributable to work-related injuries (6,000 deaths). Medical errors affect one in 10 patients worldwide. One extrapolation suggests that 180,000 people die each year partly as a result of iatrogenic injury. One in five Americans (22%) report that they or a family member have experienced a medical error of some kind.
Medical errors are associated with inexperienced physicians and nurses, new procedures, extremes of age, complex care and urgent care. Poor communication (whether in one's own language or, as may be the case for medical tourists
, another language), improper documentation, illegible handwriting, inadequate nurse-to-patient ratios, and similarly named medications are also known to contribute to the problem. Patient actions may also contribute significantly to medical errors. Falls, for example, are often due to patients' own misjudgements. Human error has been implicated in nearly 80 percent of adverse events that occur in complex healthcare systems. The vast majority of medical errors result from faulty systems and poorly designed processes versus poor practices or incompetent practitioners.
The Joint Commission's Annual Report on Quality and Safety 2007 found that inadequate communication between healthcare providers, or between providers and the patient and family members, was the root cause of over half the serious adverse events in accredited hospitals. Other leading causes included inadequate assessment of the patient's condition, and poor leadership or training.
has also been cited as a contributing factor in medical errors. One study found that being awake for over 24 hours caused medical interns to double or triple the number of preventable medical errors, including those that resulted in injury or death. The risk of car crash after these shifts increased by 168%, and the risk of near miss by 460%. Interns admitted falling asleep during lectures, during rounds, and even during surgeries.
es, sufferers of dissociative identity disorder
usually have psychiatric histories
that contain three or more separate mental disorders and previous treatment
failures. The disbelief of some doctors around the validity of dissociative identity disorder may also add to its misdiagnosis.
Studies have found that bipolar disorder
has often been misdiagnosed as major depression. Its early diagnosis necessitates that clinicians pay attention to the features of the patient's depression and also look for present or prior hypomanic or manic
symptomatology.
The misdiagnosis of schizophrenia
is also a common problem. There may be long delays of patients getting a correct diagnosis of this disorder.
, which is part of many cultural traditions, may be important in coping with medical mistakes.
However, "...those who coped by accepting responsibility were more likely to make constructive changes in practice, but [also] to experience more emotional distress." It may be helpful to consider the much larger number of patients who are not exposed to mistakes and are helped by medical care.
A 2005 study by Wendy Levinson of the University of Toronto
showed surgeons discussing medical errors used the word "error" or "mistake" in only 57 per cent of disclosure conversations and offered a verbal apology only 47 per cent of the time.
Patient disclosure is important in the medical error process. The current standard of practice at many hospitals is to disclose errors to patients when they occur. In the past, it was a common fear that disclosure to the patient would incite a malpractice lawsuit. Many physicians would not explain that an error had taken place, causing a lack of trust toward the healthcare community. In 2007, 34 states passed legislation that precludes any information from a physician’s apology for a medical error from being used in malpractice court (even a full admission of fault). This encourages physicians to acknowledge and explain mistakes to patients, and keeping an open line of communication.
The American Medical Association's Council on Ethical and Judicial Affairs states in its ethics code:
From the American College of Physicians Ethics Manual:
However, "there appears to be a gap between physicians' attitudes and practices regarding error disclosure. Willingness to disclose errors was associated with higher training level and a variety of patient-centered attitudes, and it was not lessened by previous exposure to malpractice litigation". Hospital administrators may share these concerns.
Consequently, in the United States
, many states have enacted laws excluding expressions of sympathy after accidents as proof of liability; however, "excluding from admissibility in court proceedings apologetic expressions of sympathy but not fault-admitting apologies after accidents"
Disclosure may actually reduce malpractice payments.
A newer model for improvement in medical care takes its origin from the work of W. Edwards Deming
in a model of Total Quality Management
. In this model, there is an attempt to identify the underlying system defect that allowed the opportunity for the error to occur. As an example, in such a system the error of free flow IV administration of Heparin is dealt with by not using IV heparin and substituting subcutaneous administration of heparin, obviating the entire problem. However, such an approach presupposes available research showing that subcutaneous heparin is as effective as IV. Thus, most systems use a combination of approaches to the problem.
Pharmacy
professionals have extensively studied the causes of errors in the prescribing, preparation, dispensing and administration of medications. As far back as the 1930s, pharmacists worked with physicians to select, from amongst many options, the safest and most effective drugs available for use in hospitals. The process is known as the Formulary System and the list of drugs is known as the Formulary. In the 1960s, hospitals implemented unit dose packaging and unit dose drug distribution systems to reduce the risk of wrong drug and wrong dose errors in hospitalized patients; centralized sterile admixture services were shown to decrease the risks of contaminated and infected intravenous medications; pharmacy computers screened each patient’s medication list for drug-drug interactions; and, pharmacists provided drug information and clinical decision support directly to physicians to improve the safe and effective use of medications. Pharmacists are recognized experts in medication safety and have made many contributions that reduce error and improve patient care over the last 50 years. More recently, governments have attempted to address issues like patient-pharmacists communication and consumer knowledge through measures like the Australian Government's Quality Use of Medicines
policy.
s to offset the risk and costs of lawsuits based on medical malpractice.
: while many of the factors that lead to errors in both fields are similar, aviation's error management protocols are regarded as much more effective.
Adverse effect (medicine)
In medicine, an adverse effect is a harmful and undesired effect resulting from a medication or other intervention such as surgery.An adverse effect may be termed a "side effect", when judged to be secondary to a main or therapeutic effect. If it results from an unsuitable or incorrect dosage or...
of care, whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment
Therapy
This is a list of types of therapy .* Adventure therapy* Animal-assisted therapy* Aquatic therapy* Aromatherapy* Art and dementia* Art therapy* Authentic Movement* Behavioral therapy* Bibliotherapy* Buteyko Method* Chemotherapy...
of a disease
Disease
A disease is an abnormal condition affecting the body of an organism. It is often construed to be a medical condition associated with specific symptoms and signs. It may be caused by external factors, such as infectious disease, or it may be caused by internal dysfunctions, such as autoimmune...
, injury
Injury
-By cause:*Traumatic injury, a body wound or shock produced by sudden physical injury, as from violence or accident*Other injuries from external physical causes, such as radiation injury, burn injury or frostbite*Injury from infection...
, syndrome
Syndrome
In medicine and psychology, a syndrome is the association of several clinically recognizable features, signs , symptoms , phenomena or characteristics that often occur together, so that the presence of one or more features alerts the physician to the possible presence of the others...
, behavior
Behavior
Behavior or behaviour refers to the actions and mannerisms made by organisms, systems, or artificial entities in conjunction with its environment, which includes the other systems or organisms around as well as the physical environment...
, infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
, or other ailment.
Definitions
As a general acceptance, a medical error occurs when a health-care provider chose an inappropriate method of care or the health provider chose the right solution of care but executed it incorrectly. Medical errors are often described as human errors in healthcare.However, medical error definitions are subject to debate, as there are many types of medical error from minor to major, and causality is often poorly determined.
Impact
A 2000 Institute of MedicineInstitute of Medicine
The Institute of Medicine is a not-for-profit, non-governmental American organization founded in 1970, under the congressional charter of the National Academy of Sciences...
report estimated that medical errors are estimated to result in about between 44,000 and 98,000 preventable deaths and 1,000,000 excess injuries each year in U.S. hospitals.
Some researchers questioned the accuracy of the IOM study, criticizing the statistical handling of measurement errors in the report and reporting both significant subjectivity in determining which deaths were "avoidable" or due to medical error and an erroneous assumption that 100% of patients would have survived if optimal care had been provided. A 2001 study in the Journal of the American Medical Association
Journal of the American Medical Association
The Journal of the American Medical Association is a weekly, peer-reviewed, medical journal, published by the American Medical Association. Beginning in July 2011, the editor in chief will be Howard C. Bauchner, vice chairman of pediatrics at Boston University’s School of Medicine, replacing ...
of seven Department of Veterans Affairs
Department of Veterans Affairs
Department of Veterans Affairs may refer to:*Department of Veterans' Affairs, Australia*United States Department of Veterans Affairs*Veterans Affairs Canada*Ministry of Patriots' and Veterans' Affairs...
medical centers estimated that for roughly every 10,000 patients admitted to the subject hospitals, one patient died who would have lived for three months or more in good cognitive health had "optimal" care been provided.
A 2006 follow-up to the IOM study found that medication errors are among the most common medical mistakes, harming at least 1.5 million people every year. According to the study, 400,000 preventable drug-related injuries occur each year in hospitals, 800,000 in long-term care settings, and roughly 530,000 among Medicare recipients in outpatient clinics. The report stated that these are likely to be conservative estimates. In 2000 alone, the extra medical costs incurred by preventable drug related injuries approximated $887 millionand the study looked only at injuries sustained by Medicare recipients, a subset of clinic visitors. None of these figures take into account lost wages and productivity or other costs.
According to a 2002 Agency for Healthcare Research and Quality
Agency for Healthcare Research and Quality
The Agency for Healthcare Research and Quality is a part of the United States Department of Health and Human Services, which supports research designed to improve the outcomes and quality of health care, reduce its costs, address patient safety and medical errors, and broaden access to effective...
report, about 7,000 people were estimated to die each year from medication errors - about 16 percent more deaths than the number attributable to work-related injuries (6,000 deaths). Medical errors affect one in 10 patients worldwide. One extrapolation suggests that 180,000 people die each year partly as a result of iatrogenic injury. One in five Americans (22%) report that they or a family member have experienced a medical error of some kind.
Difficulties in measuring frequency of errors
About 1% of hospital admissions have an adverse event due to negligence. However, mistakes are actually much more common, as these studies identify only mistakes that lead to measurable adverse events occurring soon after the errors. Independent review of doctors' treatment plans suggests that 14% of admissions can have improved decision-making; many of the benefits would have delayed manifestations. Even this number may be an underestimate. One study suggests that, in the United States, adults receive only 55% of recommended care . At the same time, a second study found that 30% of care in the United States may be unnecessary. For example, if a doctor fails to order a mammogram that is past due, this mistake will not show up in the first study. And because no adverse event occurred during the short follow-up of the study, the mistake also would not show up in the second study, because only the principal treatment plans were critiqued. However, the mistake would be recorded in the third study. If a doctor recommends an unnecessary treatment or test, it may not show in any of the studies.Causes
- See also Healthcare error proliferation modelHealthcare error proliferation modelThe Healthcare Error Proliferation Model is an adaptation of James Reason’s Swiss Cheese Model designed to illustrate the complexity inherent in the contemporary healthcare delivery system and the attribution of human error within these systems. The Healthcare Error Proliferation Model explains...
Medical errors are associated with inexperienced physicians and nurses, new procedures, extremes of age, complex care and urgent care. Poor communication (whether in one's own language or, as may be the case for medical tourists
Medical tourism
Medical tourism is a term initially coined by travel agencies and the mass media to describe the rapidly-growing practice of travelling across international borders to obtain health care...
, another language), improper documentation, illegible handwriting, inadequate nurse-to-patient ratios, and similarly named medications are also known to contribute to the problem. Patient actions may also contribute significantly to medical errors. Falls, for example, are often due to patients' own misjudgements. Human error has been implicated in nearly 80 percent of adverse events that occur in complex healthcare systems. The vast majority of medical errors result from faulty systems and poorly designed processes versus poor practices or incompetent practitioners.
Healthcare Complexity
- Complicated technologies, powerful drugs.
- Intensive care, prolonged hospital stay.
System and Process Design
In 2000, The Institute of Medicine released "To Err Is Human," which asserts that the problem in medical errors is not bad people in health care—it is that good people are working in bad systems that need to be made safer.- Poor communication, unclear lines of authority of physicians, nurses, and other care providers.
- Disconnected reporting systems within a hospital: fragmented systems in which numerous hand-offs of patients results in lack of coordination and errors.
- The impression that action is being taken by other groups within the institution.
- Reliance on automated systems to prevent error.
- Inadequate systems to share information about errors hamper analysis of contributory causes and improvement strategies.
- Cost-cutting measures by hospitals in response to reimbursement cutbacks.
- Environment and design factors. In emergencies, patient care may be rendered in areas poorly suited for safe monitoring. The American Institute of Architects has identified concerns for the safe design and construction of health care facilities.
- Infrastructure failure. According to the WHOWhoWho may refer to:* Who , an English-language pronoun* who , a Unix command* Who?, one of the Five Ws in journalism- Art and entertainment :* Who? , a 1958 novel by Algis Budrys...
, 50% of medical equipment in developing countries is only partly usable due to lack of skilled operators or parts. As a result, diagnostic procedures or treatments cannot be performed, leading to substandard treatment.
The Joint Commission's Annual Report on Quality and Safety 2007 found that inadequate communication between healthcare providers, or between providers and the patient and family members, was the root cause of over half the serious adverse events in accredited hospitals. Other leading causes included inadequate assessment of the patient's condition, and poor leadership or training.
Competency, Education, and Training
- Variations in healthcare provider training & experience,
- Failure to acknowledge the prevalence and seriousness of medical errors.
- The so-called July effectJuly effectThe July effect, sometimes referred to as the July phenomenon, is a perceived increase in the risk of medical errors and surgical complications that occurs in association with the time of year in which medical school graduates begin residencies....
occurs when new residents arrive at teaching hospitals, causing an increase in medication errors according to a study of data from 1979-2006.
Human Factors and Ergonomics
Sleep deprivationSleep deprivation
Sleep deprivation is the condition of not having enough sleep; it can be either chronic or acute. A chronic sleep-restricted state can cause fatigue, daytime sleepiness, clumsiness and weight loss or weight gain. It adversely affects the brain and cognitive function. Few studies have compared the...
has also been cited as a contributing factor in medical errors. One study found that being awake for over 24 hours caused medical interns to double or triple the number of preventable medical errors, including those that resulted in injury or death. The risk of car crash after these shifts increased by 168%, and the risk of near miss by 460%. Interns admitted falling asleep during lectures, during rounds, and even during surgeries.
- Fatigue,
- Depression and burnout.
- Diverse patients, unfamiliar settings, time pressures.
- Complications increase as patient to nurse staffing ratio increases.
- Drug names that look alike or sound alike.
Examples of errors
- MisdiagnosisMedical diagnosisMedical diagnosis refers both to the process of attempting to determine or identify a possible disease or disorder , and to the opinion reached by this process...
of an illness, failure to diagnose or delay of a diagnosis. This type of error could be a direct mistake of a doctor or caused when the doctor is acting on incorrect information supplied by some other person. - Giving the wrong drugMedicationA pharmaceutical drug, also referred to as medicine, medication or medicament, can be loosely defined as any chemical substance intended for use in the medical diagnosis, cure, treatment, or prevention of disease.- Classification :...
or (wrong patient, wrong chemical, wrong dose, wrong time, wrong route) - Giving two or more drugs that interact unfavorably or cause poisonous metabolicMetabolismMetabolism is the set of chemical reactions that happen in the cells of living organisms to sustain life. These processes allow organisms to grow and reproduce, maintain their structures, and respond to their environments. Metabolism is usually divided into two categories...
byproducts - Wrong-site surgerySurgerySurgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
, such as amputating the wrong limb - Retained surgical instrumentsRetained surgical instrumentsA retained surgical instrument is any item inadvertently left behind in a patient’s body in the course of surgery. There are few books about it and it is thought to be under reported. As a preventable medical error, it occurs more frequently than “wrong site” surgery...
. In particular, gossypibomaGossypibomaGossypiboma or textiloma is the technical term for a surgical complications resulting from foreign materials, such as a surgical sponge, accidentally left inside a patient's body...
, resulting from a surgical sponge being left behind inside the patient after surgery - Patients' implementation of drugs and treatments
- Using race as a diagnosis, not a factor
- Transplanting organs of the wrong blood type
- Incorrect record-keeping
Misdiagnosis of psychological disorders
Regarding mental illnessMental illness
A mental disorder or mental illness is a psychological or behavioral pattern generally associated with subjective distress or disability that occurs in an individual, and which is not a part of normal development or culture. Such a disorder may consist of a combination of affective, behavioural,...
es, sufferers of dissociative identity disorder
Dissociative identity disorder
Dissociative identity disorder is a psychiatric diagnosis and describes a condition in which a person displays multiple distinct identities , each with its own pattern of perceiving and interacting with the environment....
usually have psychiatric histories
Psychiatric history
A psychiatric history is the result of a medical process where a clinician working in the field of mental health systematically records the content of an interview with a patient...
that contain three or more separate mental disorders and previous treatment
Therapy
This is a list of types of therapy .* Adventure therapy* Animal-assisted therapy* Aquatic therapy* Aromatherapy* Art and dementia* Art therapy* Authentic Movement* Behavioral therapy* Bibliotherapy* Buteyko Method* Chemotherapy...
failures. The disbelief of some doctors around the validity of dissociative identity disorder may also add to its misdiagnosis.
Studies have found that bipolar disorder
Bipolar disorder
Bipolar disorder or bipolar affective disorder, historically known as manic–depressive disorder, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or...
has often been misdiagnosed as major depression. Its early diagnosis necessitates that clinicians pay attention to the features of the patient's depression and also look for present or prior hypomanic or manic
Manic
Manić is a suburban settlement of Belgrade, the capital of Serbia. It is located in the municipality of Barajevo.Manić developed on the eastern slopes of the Kosmaj mountain...
symptomatology.
The misdiagnosis of schizophrenia
Schizophrenia
Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social...
is also a common problem. There may be long delays of patients getting a correct diagnosis of this disorder.
Most common misdiagnoses
A 2009 meta-analysis identified the 5 most commonly mis-diagnosed diseases as: infection, neoplasm, myocardial infarction, pulmonary emboli, and cardiovascular disease. Physician familiarity with this information is variable.Outpatient vs. inpatient
- Misdiagnosis is the leading cause of medical error in out patient facilities.
- Ever since the National Institute of Medicine’s groundbreaking 1999 report, “To Err is Human,” found up to 98,000 hospital patients die from preventable medical errors in the U.S. each year, government and private sector efforts have focused on inpatient safety.
After an error has occurred
Mistakes can have a strongly negative emotional impact on the doctors who commit them.Recognizing that mistakes are not isolated events
Some doctors recognize that adverse outcomes from errors usually do not happen because of an isolated errors and actually reflect system problems. There may be several breakdowns in processes to allow one adverse outcome. In addition, errors are more common when other demands compete for a physician's attention. However, placing too much blame on the system may not be constructive.Placing the practice of medicine in perspective
Essayists imply that the potential to make mistakes is part of what makes being a physician rewarding and without this potential the rewards of medical practice would be less:- "Everybody dies, you and all of your patients. All relationships end. Would you want it any other way? [...] Don't take it personally"
- "[...] if I left medicine, I would mourn its loss as I've mourned the passage of my poetry. On a daily basis, it is both a privilege and a joy to have the trust of patients and their families and the camaraderie of peers. There is no challenge to make your blood race like that of a difficult case, no mind game as rigorous as the challenging differential diagnosis, and though the stakes are high, so are the rewards."
Disclosing mistakes
ForgivenessForgiveness
Forgiveness is typically defined as the process of concluding resentment, indignation or anger as a result of a perceived offense, difference or mistake, or ceasing to demand punishment or restitution. The Oxford English Dictionary defines forgiveness as 'to grant free pardon and to give up all...
, which is part of many cultural traditions, may be important in coping with medical mistakes.
Disclosure to oneself
Inability to forgive oneself may create a cycle of distress and increased likelihood of a future error.However, "...those who coped by accepting responsibility were more likely to make constructive changes in practice, but [also] to experience more emotional distress." It may be helpful to consider the much larger number of patients who are not exposed to mistakes and are helped by medical care.
Disclosure to patients
Patients are reported to want "information about what happened, why the error happened, how the error's consequences will be mitigated, and how recurrences will be prevented." Detailed suggestions on how to disclose are available.A 2005 study by Wendy Levinson of the University of Toronto
University of Toronto
The University of Toronto is a public research university in Toronto, Ontario, Canada, situated on the grounds that surround Queen's Park. It was founded by royal charter in 1827 as King's College, the first institution of higher learning in Upper Canada...
showed surgeons discussing medical errors used the word "error" or "mistake" in only 57 per cent of disclosure conversations and offered a verbal apology only 47 per cent of the time.
Patient disclosure is important in the medical error process. The current standard of practice at many hospitals is to disclose errors to patients when they occur. In the past, it was a common fear that disclosure to the patient would incite a malpractice lawsuit. Many physicians would not explain that an error had taken place, causing a lack of trust toward the healthcare community. In 2007, 34 states passed legislation that precludes any information from a physician’s apology for a medical error from being used in malpractice court (even a full admission of fault). This encourages physicians to acknowledge and explain mistakes to patients, and keeping an open line of communication.
The American Medical Association's Council on Ethical and Judicial Affairs states in its ethics code:
- "Situations occasionally occur in which a patient suffers significant medical complications that may have resulted from the physician's mistake or judgment. In these situations, the physician is ethically required to inform the patient of all facts necessary to ensure understanding of what has occurred. Concern regarding legal liability which might result following truthful disclosure should not affect the physician's honesty with a patient."
From the American College of Physicians Ethics Manual:
- “In addition, physicians should disclose to patients information about procedural or judgment errors made in the course of care if such information is material to the patient's well-being. Errors do not necessarily constitute improper, negligent, or unethical behavior, but failure to disclose them may.”
However, "there appears to be a gap between physicians' attitudes and practices regarding error disclosure. Willingness to disclose errors was associated with higher training level and a variety of patient-centered attitudes, and it was not lessened by previous exposure to malpractice litigation". Hospital administrators may share these concerns.
Consequently, in the United States
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...
, many states have enacted laws excluding expressions of sympathy after accidents as proof of liability; however, "excluding from admissibility in court proceedings apologetic expressions of sympathy but not fault-admitting apologies after accidents"
Disclosure may actually reduce malpractice payments.
Disclosure to non-physicians
In a study of physicians who reported having made a mistake, disclosing to non-physicians sources of support may reduce stress more than disclosing to physician colleagues. This may be due to the physicians in the same study, when presented with a hypothetical scenario of a mistake made by another colleague, only 32% physicians would have unconditionally offered support. It is possible that greater benefit occurs when spouses are physicians.Disclosure to other physicians
Discussing mistakes with other doctors is beneficial. However, doctors may be less forgiving of each other. The reason is not clear, but one essayist has admonished, "Don't Take Too Much Joy in the Mistakes of Other Doctors."Disclosure to the physician's institution
Disclosure of errors, especially 'near misses' may be able to reduce subsequent errors in institutions that are capable of reviewing near misses. However, doctors report that institutions may not be supportive of the doctor.Use of rationalization to cover up medical errors
Based on anecdotal and survey evidence, Banja states that rationalization (making excuses) is very common amongst the medical profession in covering up medical errors. Common excuses made are:- "Why disclose the error? The patient was going to die anyway."
- "Telling the family about the error will only make them feel worse."
- "It was the patient's fault. If he wasn't so (obese, sick, etc.), this error wouldn't have caused so much harm."
- "Well, we did our best. These things happen."
- "If we're not totally and absolutely certain the error caused the harm, we don't have to tell."
By harm or not harm to patient
A survey of more than 10,000 physicians in the United States came to the results that, on the question "Are there times when it's acceptable to cover up or avoid revealing a mistake if that mistake would not cause harm to the patient?", 19% answered yes, 60% answered no and 21% answered it depends. On the question "Are there times when it is acceptable to cover up or avoid revealing a mistake if that mistake would potentially or likely harm the patient?", 2% answered yes, 95% answered no and 3% answered it depends.Cause-specific preventive measures
Traditionally, errors are attributed to mistakes made by individuals who may be penalized for these mistakes. The usual approach to correct the errors is to create new rules with additional checking steps in the system, aiming to prevent further errors. As an example, an error of free flow IV administration of heparin is approached by teaching staff how to use the IV systems and to use special care in setting the IV pump. While overall errors become less likely, the checks add to workload and may in themselves be a cause of additional errors.A newer model for improvement in medical care takes its origin from the work of W. Edwards Deming
W. Edwards Deming
William Edwards Deming was an American statistician, professor, author, lecturer and consultant. He is perhaps best known for his work in Japan...
in a model of Total Quality Management
Total Quality Management
Total quality management or TQM is an integrative philosophy of management for continuously improving the quality of products and processes....
. In this model, there is an attempt to identify the underlying system defect that allowed the opportunity for the error to occur. As an example, in such a system the error of free flow IV administration of Heparin is dealt with by not using IV heparin and substituting subcutaneous administration of heparin, obviating the entire problem. However, such an approach presupposes available research showing that subcutaneous heparin is as effective as IV. Thus, most systems use a combination of approaches to the problem.
In specific specialties
The field of medicine that has taken the lead in systems approaches to safety is anaesthesiology. Steps such as standardization of IV medications to 1 ml doses, national and international color coding standards, and development of improved airway support devices has made anesthesia care a model of systems improvement in care.Pharmacy
Pharmacy
Pharmacy is the health profession that links the health sciences with the chemical sciences and it is charged with ensuring the safe and effective use of pharmaceutical drugs...
professionals have extensively studied the causes of errors in the prescribing, preparation, dispensing and administration of medications. As far back as the 1930s, pharmacists worked with physicians to select, from amongst many options, the safest and most effective drugs available for use in hospitals. The process is known as the Formulary System and the list of drugs is known as the Formulary. In the 1960s, hospitals implemented unit dose packaging and unit dose drug distribution systems to reduce the risk of wrong drug and wrong dose errors in hospitalized patients; centralized sterile admixture services were shown to decrease the risks of contaminated and infected intravenous medications; pharmacy computers screened each patient’s medication list for drug-drug interactions; and, pharmacists provided drug information and clinical decision support directly to physicians to improve the safe and effective use of medications. Pharmacists are recognized experts in medication safety and have made many contributions that reduce error and improve patient care over the last 50 years. More recently, governments have attempted to address issues like patient-pharmacists communication and consumer knowledge through measures like the Australian Government's Quality Use of Medicines
Quality use of medicines
The term Quality use of medicines is used by the Australian government as part of their policies on effective and correct uses of medicine and access to appropriate medicines.-Guiding Principles:...
policy.
Legal procedure
Standards and regulations for medical malpractice vary by country and jurisdiction within countries. Medical professionals may obtain professional liability insuranceProfessional liability insurance
Professional liability insurance , also called professional indemnity insurance but more commonly known as errors & omissions in the US, is a form of liability insurance that helps protect professional advice- and service-providing individuals and companies from bearing the full cost of defending...
s to offset the risk and costs of lawsuits based on medical malpractice.
Methods to improve safety and reduce error
Medical care is frequently compared adversely to aviationAviation
Aviation is the design, development, production, operation, and use of aircraft, especially heavier-than-air aircraft. Aviation is derived from avis, the Latin word for bird.-History:...
: while many of the factors that lead to errors in both fields are similar, aviation's error management protocols are regarded as much more effective.
- patient's informed consentInformed consentInformed consent is a phrase often used in law to indicate that the consent a person gives meets certain minimum standards. As a literal matter, in the absence of fraud, it is redundant. An informed consent can be said to have been given based upon a clear appreciation and understanding of the...
policy - patient's getting a second opinion from another independent practitioner with similar qualifications
- voluntary reporting of errors (to obtain valid data for cause analysis)
- root cause analysisRoot cause analysisRoot cause analysis is a class of problem solving methods aimed at identifying the root causes of problems or events.Root Cause Analysis is any structured approach to identifying the factors that resulted in the nature, the magnitude, the location, and the timing of the harmful outcomes of one...
- Electronic or paper reminders to help patients maintain medication adherence
- systems for ensuring review by experienced or specialist practitioners
- hospital accreditationHospital accreditationHospital accreditation has been defined as “A self-assessment and external peer assessment process used by health care organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve”...
Misconceptions
Common misconceptions about adverse events are:- "Bad apples" or incompetent health care providers are a common cause. (Although human error is commonly an initiating event, the faulty process of delivering care invariably permits or compounds the harm, and is the focus of improvement.
- High risk procedures or medical specialties are responsible for most avoidable adverse events. (Although some mistakes, such as in surgery, are harder to conceal, errors occur in all levels of care. Even though complex procedures entail more risk, adverse outcomes are not usually due to error, but to the severity of the condition being treated.). However, USPUnited States PharmacopeiaThe United States Pharmacopeia is the official pharmacopeia of the United States, published dually with the National Formulary as the USP-NF. The United States Pharmacopeial Convention is the nonprofit organization that owns the trademark and copyright to the USP-NF and publishes it every year...
has reported that medication errors during the course of a surgical procedure are three times more likely to cause harm to a patient than those occurring in other types of hospital care. - If a patient experiences an adverse event during the process of care, an error has occurred. (Most medical care entails some level of risk, and there can be complications or side effects, even unforeseen ones, from the underlying condition or from the treatment itself.
See also
- Adverse effectAdverse effectIn medicine, an adverse effect is a harmful and undesired effect resulting from a medication or other intervention such as surgery.An adverse effect may be termed a "side effect", when judged to be secondary to a main or therapeutic effect. If it results from an unsuitable or incorrect dosage or...
- Adverse eventAdverse eventAn adverse event is any adverse change in health or side effect that occurs in a person who participates in a clinical trial while the patient is receiving the treatment or within a previously specified period of time after the treatment has been completed.AEs in patients participating in...
- Serious adverse eventSerious adverse eventA serious adverse event in human drug trials are defined as any untowardmedical occurrence that at any dose#results in death,#is life-threatening#requires inpatient hospitalization or prolongation of existing hospitalization...
- Adverse drug reactionAdverse drug reactionAn adverse drug reaction is an expression that describes harm associated with the use of given medications at a normal dosage. ADRs may occur following a single dose or prolonged administration of a drug or result from the combination of two or more drugs...
- BiosafetyBiosafetyBiosafety: prevention of large-scale loss of biological integrity, focusing both on ecology and human health .Biosafety is related to several fields:*In ecology ,...
- Complication (medicine)Complication (medicine)Complication, in medicine, is an unfavorable evolution of a disease, a health condition or a medical treatment. The disease can become worse in its severity or show a higher number of signs, symptoms or new pathological changes, become widespread throughout the body or affect other organ systems. A...
- Fatal Care: Survive in the U.S. Health SystemFatal Care: Survive in the U.S. Health SystemFatal Care: Survive in the U.S. Health System is a book about preventable medical errors written by Sanjaya Kumar, president and chief medical officer of Quantros, Milpitas, California. Fatal Care was published in April 2008 by IGI Publishing, Minneapolis, Minnesota.Fatal Care: Survive in the U.S...
(book) - IatrogenesisIatrogenesisIatrogenesis, or an iatrogenic artifact is an inadvertent adverse effect or complication resulting from medical treatment or advice, including that of psychologists, therapists, pharmacists, nurses, physicians and dentists...
- Medical malpracticeMedical malpracticeMedical malpractice is professional negligence by act or omission by a health care provider in which the treatment provided falls below the accepted standard of practice in the medical community and causes injury or death to the patient, with most cases involving medical error. Standards and...
- Medical resident work hoursMedical resident work hoursMedical resident work hours is a term that refers to the often lengthy shifts worked by medical interns and residents during their medical residency. The issue has become a political football in the United States, where federal regulations do not limit the number of hours that can be assigned...
- NegligenceNegligenceNegligence is a failure to exercise the care that a reasonably prudent person would exercise in like circumstances. The area of tort law known as negligence involves harm caused by carelessness, not intentional harm.According to Jay M...
- Patient Safety and Quality Improvement ActPatient Safety and Quality Improvement ActThe Patient Safety and Quality Improvement Act of 2005 : , 42 U.S.C. , established a system of patient safety organizations and a national patient safety database...
of 2005 - Patient safety and nursingPatient safety and nursingNurses are knowledge workers whose main responsibility is to provide safe and effective care within constantly evolving health care systems. Nurses collaborate with one another, as well as doctors, aides, technicians, and others, to provide holistic care to patients...
- Patient safety organizationPatient safety organizationA patient safety organization is a group, institution or association that improves medical care by reducing medical errors. In the 1990s, reports in several countries revealed a staggering number of patient injuries and deaths each year due to avoidable adverse health care events...
- Quality Use of MedicinesQuality use of medicinesThe term Quality use of medicines is used by the Australian government as part of their policies on effective and correct uses of medicine and access to appropriate medicines.-Guiding Principles:...
- Swiss Cheese modelSwiss Cheese modelModels of accident causation are used for the risk analysis and risk management of human systems. Since the 1990s they have gained widespread acceptance and use in healthcare, in the aviation safety industry, and in emergency service organizations...
of accident causation in human systems - To Err is Human: Building a Safer Health SystemTo Err is HumanTo Err is Human: Building a Safer Health System is a report issued in November 1999 by the U.S. Institute of Medicine that may have resulted in increased awareness of U.S. medical errors. The push for patient safety that followed its release continues...
External links
- Medical Errors & Patient Safety from U.S. Dept. of Health & Human Services, Agency for Healthcare Research and Quality
- Dead by Mistake - Dead by Mistake - Hearst Newspapers Report, August 2009
- Report to the President on Medical Errors from February 2000
- Information on Medical Errors from medstat-info.org
- Report on Medical Errors from Consumers UnionConsumers UnionConsumers Union is a non-profit organization best known as the publisher of Consumer Reports, based in the United States. Its mission is to "test products, inform the public, and protect consumers."...
May 19, 2009 - The Savvy Patient Toolkit to help minimize errors