Medical error

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See also preventable medical errors

In the United States medical error is estimated to result in 44,000 to 98,000 unnecessary deaths and 1,000,000 excess injuries each year.^[1][1]. One older 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'^[1]. It is estimated that in a typical 100 to 300 bed hospital in the United States, excess costs of $1,000,000 to $3,000,000 attributable to prolonged stays and complications just due to medication errors occur yearly.

However, medical error definitions are subject to debate, as there are many types of medical error from minor to major,^[1] and causality is often poorly determined.^[1] The Health Grades study statistics, based on AHRQ MedPAR data, were based on administrative records, not clinical records, and largely overlooked multi-causality of outcomes.^[1]

Medical care is frequently compared adversely to aviation, in that, while many of the factors which lead to error are similar, aviation's error management protocols are much more effective.^[1]

An objection to this comparison is that an airplane does not take an active role in its own maintenance, while a human does (for better or worse). Furthermore, an airplane does not have input into its maintenance schedule, while a human and his/her family do. Humans are notorious for ignoring maintenance schedules and for non-compliance, while airplanes are not.

Epidemiology of medical error

Medical errors are associated with inexperienced clinicians, new procedures, extremes of age, complex care and urgent care.^[1] Poor communication, 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.

Approaches to error

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 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.

The field of medicine that has taken the lead in systems approaches to safety is Anaesthesiology.^[1] 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.

The profession of pharmacy has extensively studied the causes of errors in the prescribing, preparation, dispensing and administration of medications. As far back as the 1930’s, pharmacists worked with physicians to select from many options, the safest and most effective drugs available for use in hospitals ^[1]. The process is known as the Formulary System and the list of drugs is known as the Formulary. In the 1960’s, 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^[1]; centralized sterile admixture services were shown to decrease the risks of contaminated and infected intravenous medications^[1]; pharmacy computers screened each patient’s medication list for drug-drug interactions^[1]; and, pharmacists provided drug information and clinical decision support directly to physicians to improve the safe and effective use of medications^[1]. Pharmacists are recognized experts in medication safety and have made many contributions that reduce error and improve patient care over the last 50 years.

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.^[1]

Examples of errors

1. Misdiagnosis
2. Giving the wrong drug or (wrong patient, wrong chemical, wrong dose, wrong time, wrong route)
3. Giving two or more drugs that interact unfavorably or cause poisonous metabolic byproducts
4. Wrong site surgery such as amputating the wrong limb

Methods to improve safety and reduce error

Main article: Patient safety

1. patient's informed consent policy
2. patient's getting a second opinion from another independent practitioner with similar qualifications
3. voluntary reporting of errors (to obtain valid data for cause analysis)
4. root cause analysis
5. electronic devices (e-pill medication reminders [1]) to help patients maintain medication adherence
6. systems for ensuring review by experienced or specialist practitioners^[1]

See also

• Adverse effect (medicine)
• Biosafety
• Complication (medicine)
• Iatrogenesis
• Medical malpractice
• Preventable medical errors
• Swiss Cheese model of accident causation in human systems
• Wrong medication - medication errors
• Negligence
• Patient safety
• Total Quality Management

References

Book

• Gawande, Atul. Complications: A Surgeon's Notes on an Imperfect Science. New York, NY: Metropolitan Books; 2002.

• Wachter, Robert and Shojania, Kaveh. Internal Bleeding: The Truth Behind America's Terrifying Edidemic of Medical Mistakes. New York, NY: Rugged Land; 2004.

• Banja, John Medical Errors and Medical Narcissism, 2005

• Porter, Michael E. and Olmsted Teisberg, Elizabeth Redefining Health Care: Creating Value-Based Competition on Results, 2006

External links

• AHRQ Patient Safety Network
• AHRQ WebM&M
• Hospital Compare A tool consumers can use to compare how well U.S. hospitals care for adult patients.
• Wu AW. Medical error: the second victim. BMJ 2000; 320: 726-727
• Reason J. Human error: models and management. BMJ 2000; 320: 768-770
• "Why Doctors So Often Get It Wrong" by David Leonhardt, New York Times, Feb. 22, 2006
• Amalberti R, Auroy Y, Berwick D, et al. Five system barriers to achieve ultra safe health care. Ann Intern Med 2005;142:756-64ar:أخطاء طبية

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