Medical error

Medical errors are incidents, some of which, if not adequately corrected or compensated for, result in "medical adverse events," patient suffering, injury or even death. Although medical malpractice ordinarily involves both error and poor patient outcome, medical errors and malpractice are not the same. In medical malpractice, there is always a component of negligence or failure to meet an acceptable standard of care on the part of the caregiver. In theory, if all caregivers performed within the bounds of professional excellence, the incidence of medical malpractice could be reduced to zero. Errors, on the other hand, are made by every health care worker in every hospital and health care facility. In fact, errors are made by the best trained and most intelligent physicians, nurses, and pharmacists even when diligently following the highest standards of care. The reason is straightforward: in any human system, error can occur and therefore, eventually, does occur. The incidence of error in medical care can be reduced, but never totally eliminated.

In one sense, however, there is a difference between human error on the part of medical personnel and the term 'medical error'. That difference is a matter of correction before an error results in harm to the patient. Medical errors are actions, or omissions, on the part of physicians, nurses and other caregivers that lead to a suboptimal result for the patient. In other words, an error that is recognized immediately and fully remedied does not go on to have untoward consequences. There are some errors that, once committed, cause irreparable harm, like sudden death or brain damage - but these are the great minority of actions. Ordinarily, a bad result occurs as the result of more than one error, an initial mistake followed by at least one subsequent failure to recognize and counter it.

"In 2001, the U.S. Institute of Medicine estimated the risks of medical error-related deaths in the United States to be 44,000–98,000 deaths per year, letting aside other serious adverse events".

On-going strategies for reduction of medical error

Within the health sciences, there have been varying approaches to reducing medical errors.

One approach is to apply lessons from aviation, "plane crashes are often spectacular and well publicized, resulting sometimes in significant loss of life. Consequently all plane crashes and other serious incidents are exhaustively investigated and analyzed with respect to cause. On the other hand, most medical errors do not have the same spectacular effects, thus do not usually receive the same intense scrutiny and analysis."

Adaptation of a "pilot's checklist" to prepare for take-off and landing has been tested for use for usefulness in preparation for the performance of Cesarean delivery under general anesthesia.

Improvement of medical personel.

Reduction of duty hours

Myers JS. Bellini LM. Morris JB. Graham D. Katz J. Potts JR. Weiner C. Volpp KG. Internal medicine and general surgery residents' attitudes about the ACGME duty hours regulations: a multicenter study.[see comment]. [Journal Article. Multicenter Study. Research Support, U.S. Gov't, Non-P.H.S.] Academic Medicine. 81(12):1052-8, 2006 Dec. UI: 17122468

Organizations promoting error reduction

Institute for Healthcare Improvement

The Institute for Healthcare Improvement (IHI) defines medical harm as "unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment) that requires additional monitoring, treatment or hospitalization, or results in death." Previously, IHI initiated the 100,000 Lives Campaign. That campaign, participated in by 3,200 hospitals, is estimated to have reduced deaths of patients in hospitals by 122,000 in 18 months. The campaign focused on 6 "interventions" which had been identified as likely to reduce medical error:

1. Deploy Rapid Response Teams… at the first sign of patient decline – and before a catastrophic cardiac or respiratory event.
2. Deliver reliable, evidence-based care for acute myocardial infarction…to prevent deaths from heart attack.
3. Prevent adverse drug events…by reconciling patient medications at every transition point in care.
4. Prevent central line infections…by implementing a series of interdependent, scientifically grounded steps.
5. Prevent surgical site infections…by following a series of steps, including reliable, timely administration of correct perioperative antibiotics.
6. Prevent ventilator-associated pneumonia…by implementing a series of interdependent, scientifically grounded steps.

IHI's second campaign, the 5 Million Lives Campaign, challenges 4,000 hospitals to adopt at least one of twelve interventions: the six original interventions and six more:

1. Prevent methicillin-resistant Staphylococcus aureus (MRSA) infection...by reliably implementing scientifically proven infection control practices throughout the hospital
2. Reduce harm from high-alert medications...starting with a focus on anticoagulants, sedatives, narcotics, and insulin
3. Reduce surgical complications...by reliably implementing the changes in care recommended by the Surgical Care Improvement Project (SCIP)
4. Prevent pressure ulcers...by reliably using science-based guidelines for prevention of this serious and common complication
5. Deliver reliable, evidence-based care for congestive heart failure…to reduce readmissions
6. Get boards on board…by defining and spreading new and leveraged processes for hospital boards of directors, so that they can become far more effective in accelerating the improvement of care

The goal is encourage hospitals to improve their procedure enough to eliminate five million incidents of medical harm during a 24-month period, ending Dec. 9, 2008.

The Patient Advocate

Reduction of medical error can be effected on the patient side as well as on the side of the care giver, but only with vigilence on the part of the patient him or herself, or on the part of the patient's advocate.

Notes

References

• "The University of Texas Threat and Error Management Model:Components and Examples" PDF file Robert L. Helmreich and David M. Musson (link to BMJ is not good)
• "Error, stress, and teamwork in medicine and aviation: cross sectional surveys" paper by J Bryan Sexton, Eric J Thomas, and Robert L Helmreich, BMJ 2000;320:745-749 ( 18 March )
• "On error management: lessons from aviation" article by Robert L Helmreich, BMJ 2000;320:781-785 ( 18 March )
• "IHI Launches National Initiative to Reduce Medical Harm in U.S. Hospitals, Builds on 100,000 Lives Campaign"
• The Wikipedia article "Medical error" was consulted during the writing of this article and certain materials referenced in it were used.
• "Relationship between tort claims and patient incident reports in the Veterans Health Administration", article by J M Schmidek and W B Weeks, Qual Saf Health Care 2005;14:117-122 Shows incompleteness results even from a mandatory reporting system, "With a self-reporting system all reporting is voluntary."
• "Incident Reporting Systems in Medicine and Experience With the Aviation Safety Reporting System" Charles Billings, MD, "A Tale of Two Stories", National Patient Safety Foundation, Report from a Workshop on Assembling the Scientific Basis for Progress on Patient Safety

Further Reading

• Nancy Berlinger, After Harm: Medical Error And The Ethics Of Forgiveness, John Hopkins University Press (May, 2005), hardcover, 156 pages, ISBN 0801-88167-6
  • Review BMJ
• Janet Corrigan, Molla S. Donaldson, and Linda T. Kohn, editors, To Err Is Human: Building a Safer Health System, National Academy Press (April, 2000), hardcover, 287 pages, ISBN 0309-06837-1
  • Eight page summary (PDF file)
  • Searchable full text online
• Atul Gawande, Complications: A Surgeon's Notes on an Imperfect Science, ISBN 0-312-42170-2
• Committee on Quality of Health Care in America, Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century, National Academy Press (July, 2001), hardcover, 337 pages, ISBN 0309-07280-8
  • Searchable full text online
• Kathleen M. Sutcliffe, Marilynn M. Rosenthal, editors, Medical Error: What Do We Know? What Do We Do? John Wiley and Sons (July, 2002}, hardcover, 325 pages, ISBN 0787-96395-X
  • Review BMJ

External links

• University of Texas Human Factors Research Project
• AHRQ WebM&M (Morbidity and Mortality Rounds on the Web)