Medical error

Medical errors are mistakes that are made in a medical setting. Errors are made by every type of health care worker, and in every hospital and health care facility. In 2001, the U.S. Institute of Medicine estimated that, every year, 44,000–98,000 deaths in the USA were related to medical errors.

Errors are not limited to medical workers and may include any decision maker involved in medical care, including the patient themselves. For example, reimbursements by medical insurance may be poorly structured resulting in less than optimal outcomes.

When an error occurs, the key question becomes, will it be recognized and corrected? Errors that eventually result in injury are typically compounded by subsequent errors of not recognizing that an error has occurred, and not taking remedial action.

Epidemiology/frequency

Errors may occur among hospitalized patients, ambulatory patients, or patients after discharge from the hospital.

The frequency of errors is higher when physicians and patients are asked about their experience with errors among their families.

The frequency of meaningful medical error is debated.

Most patients in intensive care experience at least one error.

Reporting requirements

In the United States reporting medical errors in hospitals is a condition of payment by Medicare. An investigation by the Office of Inspector General, Department of Health and Human Services released January 6, 2012 found that most errors are not reported and even in the case of errors that are reported and investigated changes are seldom made which would prevent them in the future. The investigation revealed that there was often lack of knowledge regarding which events were reportable and recommended that lists of reportable events be developed.

Classification

Errors can be classified into "no fault," "system-related", and "cognitive".

No fault

Examples including overlooking a disease that in a patient with manifestations so atypical that most doctors would not be expected to recognize the underlying disease.

System-related

Examples of system errors include "problems with policies and procedures, inefficient processes, teamwork, and communication." Errors may happen during transfer of care. In medical training, breakdowns in teamwork (including supervision) are a cause, especially at the beginning of the academic year.

Interruptions have a complicated affect on error and cognition.

Unclear instructions to health personnel

Unclear prose, whether in institutional instructions or reports, may contribute to errors.

Ill-defined clinical flow processes

The results of abnormal diagnostic tests may not acted upon.

Work load

Examining errors in administration of parenteral medications in intensive care, a study found:

• 74 errors per 100 patient-days
• Independent risk factors were:
  • Patient complexity as measured by
    • number of organ failures
    • number of parenteral administrations
  • Work load as measured by
    • Larger intensive care unit
    • Increased ratio of patient turnover to the size of the unit
    • Number of patients per nurse
    • Occupancy rate of the unit

Workload may also be associated with adverse outcomes in emergency rooms.

On the other hand, insufficient volume of care is associated with reduced quality of care.

Inadequate staffing

Many studies show that adverse events are associated with low staffing.

Weekends and off hours

Inadequate provision of medical care for patients admitted on weekends may increase adverse outcomes in most but not all studies. The same may be true for in-hospital cardiac arrest. "The weekend effect was larger in major teaching hospitals compared with nonteaching hospitals."

The reduced quality of care during off hours may improve as a hospital has more experience in quality improvement.

Failure to rescue

Hospitals have similar incidence of surgical complications, yet varying incidence of nosocomial death. This suggests that some hospitals have a "failure to rescue" patients from complications.

Cognitive

Voytovich has suggested that diagnostic error due to cognitive errors can be further classified into omission of finding, premature closure, inadequate synthesis, and wrong formulation. Similarly, Graber has classified cognitive error into faulty knowledge, faulty data gathering, and faulty synthesis (usually premature closure). An additional classification has been proposed by Kassirer. In medical trainees, cognitive errors are an important cause or medical error. The many cognitive biases that can lead to cognitive error have been inventoried.

Omission of finding

An example is recording a finding during data collection, but not including the finding on the problem list.

Faulty data gathering

An example of faulty data gathering is and incomplete physical examination or not ordering needed tests.

Premature closure

Premature closure is the most common cognitive error.

Wrong formulation

Examples of wrong formulation or flawed reasoning are making a diagnosis that is contradicted by clinical findings.

Inadequate knowledge

Inadequate knowledge can be a factor, but is uncommon as an isolated problem in studies of causes of medical errors. However, inadequate knowledge was found to be a more common problem in study of appropriateness of care among patients without identified medical errors. It is unclear how often each of the types of cognitive errors such as an incomplete evaluation, omission of a finding, wrong formulation, are partly due to inadequate knowledge of diseases.

System-related cognitive deficits

At the interface between system-related errors and cognitive errors, one finds the errors that are learnt in the course of the formative years, in medical schools.

Needless to say, doctors are expected to have a very high degree of moral development: the profession requires an ability to make choices that will impact on the quality of life of innumerable patients, and to act appropriately and diligently when faced with life-or-death situations. Doctors are expected to master an enormous amount of knowledge, and to advance beyond when faced with the grey areas of clinical practice.

It is recognized that higher education has a favourable impact on moral development: university students tend to reason more in societal and principled terms when faced with ethical issues, and less in terms of self-interest or peer approval, the more they advance in their university curriculum. The medical curriculum is a notable exception to this rule.

It is now recognized that medical education, as it is today, hinders moral development.The reason why medical education forms doctors that will be less able to take ethical decisions than other professionals with comparable levels of education is still not known with certainty, although the so-called "hidden curriculum" appears to be a likely culprit.

Patient related

Patients who have more medical problems and more complaints may have reduced quality of care due to competing demands on physician time.

Malpractice

If an error involves negligence and results in damage, as those terms are legally defined, it may be treated as medical malpractice and result in substantial liability. The possibility of legal liability can be a barrier to free discussion and disclosure of medical error, hampering efforts to reduce error. Thus, provisions for confidential reporting of errors can be useful.

Prevention

Lessons from aviation

Plane crashes can be dramatic events, causing considerable loss of life and attracting wide publicity damaging to the reputation of the airlines involved, and weakening passenger confidence in air travel. Accordingly, all plane crashes and related serious incidents ("near misses") are exhaustively investigated in an effort to establish their precise causes. By comparison, most medical errors do not have the same wide impact, thus they seldom receive such intense scrutiny and analysis.

An adapted version of a "pilot's checklist" (designed to ensure that safety procedures are rigorously followed when preparing for take-off and landing) has been tested for usefulness in preparation for performing Cesarean delivery under general anesthesia.

Another aviation safety method, with potential healthcare benefit, is crew resource management (CRM), also called cockpit resource management. While the captain of an aircraft is the ultimate authority, CRM helps ensure that all crew members are proactive in sharing safety-related information. Some of CRM principles include peer monitoring, acceptance that team members do make errors, and that each team member has responsibility both for the patient and for situational awareness. The method cannot be transferred directly to medicine, but has potential to be modified to medicine.

Some of the differences include that cockpit crew are usually all certified pilots with differing levels of experience in the same basic skill set, while healthcare teams involve people not only with different levels of experience, but different skills and lack of skills. A surgeon may not have the physiologic intuition of an anesthesiologist, but the surgeon is the authority. An experienced surgical nurse may see a young surgeon about to make an error, but a concept of nurse vs. physician roles may reduce the chance of a warning being issued, or perhaps being accepted.

Aviators also have one motivator that is far less common than in medicine: shared fate. While a break in barrier methods may infect a healthcare team member, the implications are not as drastic as the failure of a copilot to assert the aircraft did not have adequate takeoff speed, which should have caused the takeoff to be aborted, rather than Air Florida 93 crashing into the 14th Street Bridge in Washington DC.

Hospital design

See also: electronic medical record, electronic health record, clinical decision support system, and medical order entry system.

Patients placed in isolation rooms for infection control "experience more preventable adverse events, express greater dissatisfaction with their treatment, and have less documented care."

Bar coding medication administration may reduce errors.

Personnel factors

Sleep deprivation

Sleep deprivation may contribute to errors.

Reduction of duty hours

See also Medical education

A survey of 200 residents who trained both before and after duty hours reform reported improved quality of life. However, "Residents reported that whereas fatigue-related errors decreased slightly, errors related to reduced continuity of care significantly increased." Resident believe excessive work hours is a common cause of medical error.

Restricting duty hours may or may not improve performance. However, restrictions may be costly.

Oversight of professional conduct

It is not clear that the oversight of professional conduct prevents errors.

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."

100,000 Lives Campaign

In 2004, the 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 six "interventions", three focused on common hospital-acquired (nosocomial infections), which had been identified as likely to reduce medical error:

1. "Deploy Rapid Response Teams…at the first sign of patient decline". Rapid Response Teams (RRSs) are teams of critical care experts. Use of Rapid Response Teams has increased dramatically in U.S. Hospitals, from near zero in 2003 to 1500 in 2006. RRSs have been helpful in some, but not all studies.
2. "Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack."
3. "Prevent Adverse Drug Events (ADEs)…by implementing medication reconciliation."
4. "Prevent Central Line Infections…by implementing a series of interdependent, scientifically grounded steps called the "Central Line Bundle"."
5. "Prevent Surgical Site Infections…by reliably delivering the correct perioperative antibiotics at the proper time." Significant reduction may be achieved by procedures as simple as proper hand washing, use of clippers rather than razors to shave the site of surgery, or prompt administration of antibiotics following surgery.
6. "Prevent Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps including the 'Ventilator Bundle'."

5 Million Lives Campaign

IHI's second campaign, the 5 Million Lives Campaign, aims to eliminate five million incidents of medical harm during a 24-month period, ending Dec. 9, 2008. The campaign challenges 4,000 hospitals to adopt at least one of twelve interventions: the six original interventions and the following six more:

1. "Prevent Harm from High-Alert Medications... starting with a focus on anticoagulants, sedatives, narcotics, and insulin."
2. "Reduce Surgical Complications... by reliably implementing all of the changes in care recommended by SCIP, the Surgical Care Improvement Project (http://www.medqic.org/scip)."
3. "Prevent Pressure Ulcers... by reliably using science-based guidelines for their prevention."
4. "Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) infection…by reliably implementing scientifically proven infection control practices."
5. "Deliver Reliable, Evidence-Based Care for Congestive Heart Failure... to avoid readmissions."
6. "Get Boards on Board … by defining and spreading the best-known leveraged processes for hospital Boards of Directors, so that they can become far more effective in accelerating organizational progress toward safe care."

Agency for Healthcare Research Quality

The American Agency for Healthcare Research and Quality has established 11 priority areas:

1. Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk.
2. Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality.
3. Use of maximum sterile barriers while placing central intravenous catheters to prevent infections.
4. Appropriate use of antibiotic prophylaxis in surgical patients to prevent perioperative infections.
5. Asking that patients recall and restate what they have been told during the informed consent process.
6. Continuous aspiration of subglottic secretions (CASS) to prevent ventilator-associated pneumonia.
7. Use of pressure relieving bedding materials to prevent pressure ulcers.
8. Use of real-time ultrasound guidance during central line insertion to prevent complications.
9. Patient self-management for warfarin (CoumadinTM) to achieve appropriate outpatient anticoagulation and prevent complications.
10. Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients.
11. Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections.

Joint Commission

The Joint Commission promotes a number of goals that are listed at http://www.jcrinc.com/National-Patient-Safety-Goals/.

United States Surgeon General

The United States of America Surgeon General has announced calls to action to improve medical care in the following areas:

• Prevent Deep Vein Thrombosis and Pulmonary Embolism
• Prevent and Reduce Underage Drinking
• The Surgeon General’s Call to Action to Improve the Health and Wellness of Persons with Disabilities
• National Call To Action To Promote Oral Health
• Prevent and Decrease Overweight and Obesity
• Promote Sexual Health and Responsible Sexual Behavior
• Prevent Suicide

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 vigilance on the part of the patient him or herself, or on the part of the patient's advocate.

Payment

Generally medical treatment to correct medical error has been considered billable, but effective October 1, 2008 Medicare will discontinue paying hospitals for treatment resulting from 10 common medical errors. Other insurance carriers are expected to follow suit. In addition to 7 other conditions, the errors which not will be paid for include three "never events": objects left in the body during surgery, air embolisms and blood incompatibility.

Serious Reportable Events

The full list of "never events", serious reportable events, was developed by the National Quality Forum (NQF) in 2002, and refined in 2006. It includes the following:

Surgical Events

• Surgery performed on the wrong body part
• Surgery performed on the wrong patient
• Wrong surgical procedure performed on a patient
• Unintended retention of a foreign object in a patient after surgery or other procedure
• Intraoperative or immediately postoperative death in an ASA Class I patient

Product of Device Events

• Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility
• Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended
• Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility

Patient Protection Events

• Infant discharged to the wrong person
• Patient death or serious disability associated with patient leaving the facility without permission
• Patient suicide, or attempted suicide, resulting in serious disability while being cared for in a healthcare facility

Care Management Events

• Patient death or serious disability associated with a medication error (e.g. errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)
• Patient death or serious disability associated with a hemolytic reaction (abnormal breakdown of red blood cells) due to the administration of ABO/HLA – incompatible blood or blood products
• Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility
• Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
• Death or serious disability associated with failure to identify and treat hyperbilirubinemia (condition where there is a high amount of bilirubin in the blood) in newborns
• Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
• Patient death or serious disability due to spinal manipulative therapy
• Artificial insemination with the wrong donor sperm or wrong egg

Environmental Events

• Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility
• Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
• Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
• Patient death or serious disability associated with a fall while being cared for in a healthcare facility
• Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility

Criminal Events

• Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
• Abduction of a patient of any age
• Sexual assault on a patient within or on the grounds of a healthcare facility
• Death or significant injury of a patient or staff member resulting form a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility

The physician's perspective

Medical case reports review the strongly negative emotional impact of mistakes on the doctors who allegedly commit them.

Coping mechanisms

Essays and studies have described physician coping mechanisms.

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, competing demands on the provider's attention can reduce quality of care. However, placing too much blame on the system may not be constructive.

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

Forgiveness, which is a part of many religions, may be important in coping with medical mistakes.

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 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.

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.

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 of America, 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.

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.

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.

See also

• Medical malpractice
• Health care quality assurance