Preventable medical error
According to WHO, medical errors affect one in 10 patients worldwide. 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.[1] 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.[2]
All medical errors are a significant patient safety concern. Those "medical errors" that are considered "preventable" represent an area for continued research. This research is necessary as the majority of medical errors are considered to be preventable. Healthcare professionals accept the fact that there will always be human error in medicine that causes patient harm. The list of preventable medical errors includes: retained surgical instruments, wrong site surgery, administering the wrong medication when the correct one was ordered, or transplanting organs of the wrong blood type. On the other hand, less obvious and more diffifult to reconcile medical errors include those preventable errors illustrated in journal case study reports where one or more experts review the treatment decisions of a clinician and conclude that the clinician's judgment was incorrect.
Contents
Nature and extent
Despite remarkable progress in health care technology and delivery, too many patients die or are injured as a consequence of medical errors. A study focusing on 2002-2004 hospitalizations in the U.S. revealed that about 83,000 potentially preventable deaths occurred each year. Medical errors occur in hospitals and other health care settings, such as clinics, physicians' offices, pharmacies, nursing homes, urgent care centers and patients' home. [3]
- The Commonwealth Fund, 2002, suggests that one in five Americans (22%) report that they or a family member have experienced a medical error of some kind.
- The Office of the Medical Inspector at the Veterans Administration (VA) reported a total of 2,927 medical errors from June 1997 to December 1998, more than 700 of which resulted in accidental patient deaths or suicides.
- According to the Agency for Healthcare Research and Quality, 2002, about 7,000 people are estimated to die each year from medication errors - about 16 percent more deaths than the number attributable to work-related injuries (6,000 deaths).
- Findings of the Institute of Medicine, 1999, show that in all U.S. hospitals the increased costs of preventable medication errors cost the economy about $2 billion each year.[4]
- One extrapolation suggests "180,000 people die each year partly as a result of iatrogenic injury, the equivalent of three jumbo-jet crashes every 2 days"[5]
- According to a 2005 study of 39 million patient records, 241,280 deaths during Medicare hospitalizations were attributable to one or more common preventable medical errors. In each year from 2001 through 2003, the study found that the number of medical errors or "patient safety incidents" at America's hospitals was approximately 1.18 million, with a cost to Medicare of nearly $3 billion annually.[6]
Difficulties in measuring frequency of errors
About 1% of hospital admissions have an adverse event due to negligence [7]. 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[8]. Even this number may be an underestimate. One study suggests that, in the United States, adults receive only 55% of recommended care [9]. At the same time, a second study found that 30% of care in the United States may be unnecessary [10]. For example, if a doctor fails to order a mammogram that is past due, this mistake will not show up in the first study[7]. 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[8], 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.
Most common causes
- See also Healthcare error proliferation model
Most medical errors could be avoided if the doctors, nurses, dentists and other practitioners took more care.
- Misdiagnosis 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.
- Inappropriate communication between various medical service providers or between providers and patients.
- Incorrect record-keeping
- Increased shortage of nurses.
- Inappropriate or substandard treatment, or failure to provide treatment. There may be errors in prescribing medication or mishandling of medications. There may be failure of hospital staff or a pharmacist to dispense the right medicine to the right patient in the correct amount.
- Overwork and tiredness of medical staff called on to perform extra duties. Nurses whose shift exceeds 12.5 hours are three times more likely to make a medical error than the nurse who works 8.5 hours or less. The error rate increases similarly after a nurse puts in more than 40 hours a week, regardless of the length of shifts.[citation needed]
- Lack of more safeguards or checking-points in the health care system.[11]
- Failure to follow-up on a patient
- Failure to informed consent
- Failure to prevent patient injuries (such as falls) on medical facility property
- Failure to follow advance directives
According to the federal government's Agency for Healthcare Research and Quality (AHRQ), some subspecialty-specific medical errors of major importance are:
- Birth injuries. Oxygen deprivation is one major cause and so it mechanical trauma. This may occur when the baby assumes an unusual position at the time of birth or when the baby is too large to pass through the birth canal easily.
- Surgical Complications
- Anesthesia-related complications, e.g. failure to safely administer anesthesia
Medical errors often result as a consequence of several factors.
The physician's perspective
Mistakes can have a strongly negative emotional impact on the doctors who commit them.[12][13][14][15]
Coping mechanisms
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.[16] There may be several breakdowns in processes to allow one adverse outcome.[17] In addition, errors are more common when other demands compete for a physician's attention.[18][19][20] However, placing too much blame on the system may not be constructive.[16]
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"[21]
- "... 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."[22]
Disclosing mistakes
Forgiveness, which is part of many cultural traditions, may be important in coping with medical mistakes.[23]
Disclosure to oneself
Inability to forgive oneself may create a cycle of distress and increased likelihood of a future error.[24]
However, "...those who coped by accepting responsibility were more likely to make constructive changes in practice, but [also] to experience more emotional distress."[25] It may be helpful to consider the much larger number of patients who are not exposed to mistakes and are helped by medical care.[22]
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."[26] Detailed suggestions on how to disclose are available.[27]
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[28]:
- “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".[29] Hospital administrators may share these concerns.[30]
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"[31]
Disclosure may actually reduce malpractice payments.[32][33]
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[34]. 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[35].
Disclosure to other physicians
Discussing mistakes with other doctors is beneficial.[16] However, doctors may be less forgiving of each other.[35] The reason is not clear, but one essayist has admonished, "Don't Take Too Much Joy in the Mistakes of Other Doctors."[36]
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.[37] However, doctors report that institutions may not be supportive of the doctor.[16]
See also
References
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Coping mechanisms:
- An essay: Oscar London (1987). "Rule 13: When You Make a Mistake So Horrible It is to Die Over, Don't". Kill as few patients as possible: and fifty-six other essays on how to be the world's best doctor. Berkeley, Calif: Ten Speed Press. pp. 23–24. ISBN 0-89815-197-X.
- A study: Quill TE, Williamson PR. Healthy approaches to physician stress. Arch Intern Med. 1990;150:1857-61. PMID 2393317
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