Preventable medical error

Preventable medical error

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 carried it out incorrectly.

In practice the term "medical errors" is often preceded by the modifier "preventable." Medical world accepts that there are some medical errors for which preventability is rarely questioned. The list includes medical errors such as 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, there are and less preventable medical errors such as case studies reported in journals, where one or more experts review the treatment decisions of a clinician and conclude that the clinician's judgment was incorrect.

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 2002-2004 hospitalization in US reveals that about 83,000 potentially preventable deaths occurred each year. Beside hospitals, medical also occur in other health care settings such as clinics, physicians' offices, pharmacies, nursing homes, urgent care centers and the care delivered in the home. [ [http://www.healthgrades.com/media/dms/pdf/PatientSafetyInAmericanHospitalsStudy2006.pdf] HealthGrades Third Annual Patient Safety in American Hospitals Study April 2006]

* 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 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 Institute of Medicine, 1999 appreciate that in all US hospitals, the increased costs of preventable medication errors costs the economy about $2 billion each year. [ [http://www.npsf.org/html/StandUp/about_medical_errors.html] About Medical Errors]
* 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'cite journal |author=Leape LL |title=Error in medicine |journal=JAMA |volume=272 |issue=23 |pages=1851–7 |year=1994 |pmid=7503827 |doi=10.1001/jama.272.23.1851]

Difficulties in measuring frequency of errors

Althougt about 1% of hospital admissions have an adverse event due to negligence cite journal |author=Brennan T, Leape L, Laird N, Hebert L, Localio A, Lawthers A, Newhouse J, Weiler P, Hiatt H |title=Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I |journal=N Engl J Med |volume=324 |issue=6 |pages=370–6 |year=1991 |pmid=1987460] , mistakes are actually much more common as these studies only identify mistakes that lead to measurable adverse events occurring soon after the error. Independent review of doctors' treatment plans suggest that 14% of admissions can have improved decision making; many of the benefit would have delayed manifestationscite journal |author=Lucas B, Evans A, Reilly B, Khodakov Y, Perumal K, Rohr L, Akamah J, Alausa T, Smith C, Smith J |title=The impact of evidence on physicians' inpatient treatment decisions |journal=J Gen Intern Med |volume=19 |issue=5 Pt 1 |pages=402–9 |year=2004 | doi = 10.1111/j.1525-1497.2004.30306.x | pmid=15109337] . Even this number may be an underestimate. One study suggests that in the United States adults only receive 55% of recommended care McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(:2635-45. PMID 12826639] while at the same time a second study found that 30% of care in the United States may be unnecessary Fisher ES. Medical care--is more always better? N Engl J Med. 2003 Oct 23;349(17):1665-7. PMID 14573739] . For example, if a doctor fails to order a mammogram that is past due, this mistake will not show up in the first study.] because no adverse event occurred during the short follow up of the study, the mistake would also not show up in the second study.] because only the principle treatment plans were critiqued, but the mistake would be recorded in the third study. If a doctor recommends a unnecessary treatment or test it may not show in any of the studies.

Most common causes

The next list of potential causes is not exclusive, but it does cover the main areas and most medical errors could be avoided if the doctors, nurses, dentists and other practitioners took more care.

* Diagnostic errors. 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.
* Incorrect record keeping
* Errors in prescribing medication.
* Overwork and tiredness of medical staff called on to perform extra duties.
* Lack of more safe guards or checking points of healthcare system. [ [http://www.nap.edu/books/0309068371/html/] To Err Is Human: Building a Safer Health System, 2000, Institute of Medicine]

An important conclusion of the above list is that the medical errors often result as a consequence of many factors.

Medical errors and medical malpractice

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. [ [http://www.healthgrades.com/media/DMS/pdf/DHAPSNationalReleaseFINAL4May022005.pdf.] HealthGrades, Medical Errors Gap Widens Between Best and Worst Hospitals: Healthgrades Study, (May 2005) ]

Most common preventable medical errors leading to malpractice

The federal government's Agency for Healthcare Research and Quality (AHRQ) found that 18 categories of medical errors, such as postoperative infections, accidental reopening of surgical wounds, and medical objects left inside patients, result in 32,500 hospital deaths, cost $9.3 billion in additional hospital charges, and lead to over 2.4 million extra days spent in hospitals

* Misdiagnosis of an illness, failure to diagnose or delay of a diagnosis
* 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
* Mishandling of medications
* Prescription Errors
* Failure of hospital staff or a pharmacist to dispense the right medicine to the right patient in the correct amount
* Inappropriate or substandard treatment
* Failure to provide treatment
* Failure to follow-up on a patient
* Failure to informed consent
* Anesthesia-related complications
* Failure to safely administer anesthesia
* Failure to prevent patient injuries (such as falls) on medical facility property
* Failure to follow Advance Directive An advance directive tells your doctor what kind of care you would like to have if you become unable to make medical decisions.

The physician's perspective

Case reports review the strongly negative emotional impact of mistakes on the doctors who commit them.cite journal |author=Hilfiker D |title=Facing our mistakes |journal=N. Engl. J. Med. |volume=310 |issue=2 |pages=118–22 |year=1984 |pmid=6690918 |doi=] cite journal |author=Christensen JF, Levinson W, Dunn PM |title=The heart of darkness: the impact of perceived mistakes on physicians |journal=Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine |volume=7 |issue=4 |pages=424–31 |year=1992 |pmid=1506949 |doi=] cite journal |author=Wu AW |title=Medical error: the second victim. The doctor who makes the mistake needs help too |journal=BMJ |volume=320 |issue=7237 |pages=726–7 |year=2000 |pmid=10720336 |doi=] cite journal |author=Waterman AD, Garbutt J, Hazel E, Dunagan WC, Levinson W, Fraser VJ, Gallagher TH. |title=The Emotional Impact of Medical Errors on Practicing Physicians in the United States and Canada |journal=Joint Commission Journal on Quality and Patient Safety |volume=33 |issue= |pages=467–476 |year=2007 |pmid=6690918 |doi=|url=http://www.ingentaconnect.com/content/jcaho/jcjqs/2007/00000033/00000008/art00001]

Coping mechanisms

Essayscite book |author=Oscar London |chapter=Rule 13: When You Make a Mistake So Horrible It is to Die Over, Don't|title=Kill as few patients as possible: and fifty-six other essays on how to be the world's best doctor |publisher=Ten Speed Press |location=Berkeley, Calif |year=1987 |pages=23-24 |isbn=0-89815-197-X |oclc= |doi=] and studiesQuill TE, Williamson PR. Healthy approaches to physician stress. Arch Intern Med. 1990;150:1857-61. PMID 2393317 ] cite journal |author=Newman MC |title=The emotional impact of mistakes on family physicians |journal=Archives of family medicine |volume=5 |issue=2 |pages=71–5 |year=1996 |pmid=8601210 |doi=] have described physician 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.cite journal |author=Wu AW, Folkman S, McPhee SJ, Lo B |title=Do house officers learn from their mistakes? |journal=JAMA |volume=265 |issue=16 |pages=2089–94 |year=1991 |pmid=2013929 |doi=] There may be several breakdowns in processes to allow one adverse outcome. cite journal |author=Gandhi TK, Kachalia A, Thomas EJ, "et al" |title=Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims |journal=Ann. Intern. Med. |volume=145 |issue=7 |pages=488–96 |year=2006 |pmid=17015866 |doi=] In addition, errors are more common when other demands compete for a physician's attention.cite journal |author=Redelmeier DA, Tan SH, Booth GL |title=The treatment of unrelated disorders in patients with chronic medical diseases |journal=N. Engl. J. Med. |volume=338 |issue=21 |pages=1516–20 |year=1998 |pmid=9593791 |doi=] cite journal |author=Lurie N, Rank B, Parenti C, Woolley T, Snoke W |title=How do house officers spend their nights? A time study of internal medicine house staff on call |journal=N. Engl. J. Med. |volume=320 |issue=25 |pages=1673–7 |year=1989 |pmid=2725617 |doi=] cite journal |author=Lyle CB, Applegate WB, Citron DS, Williams OD |title=Practice habits in a group of eight internists |journal=Ann. Intern. Med. |volume=84 |issue=5 |pages=594–601 |year=1976 |pmid=1275366 |doi=] 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"cite book |author=Thomas Laurence, |chapter=What Do You Want?|title=Extreme Clinic -- An Outpatient Doctor's Guide to the Perfect 7 Minute Visit |publisher=Hanley & Belfus |location=Philadelphia |year=2004 |pages=120 |isbn=1-56053-603-9 |oclc= |doi=]
* "... 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."cite journal |author=Seder D |title=Of poems and patients |journal=Ann. Intern. Med. |volume=144 |issue=2 |pages=142 |year=2006 |pmid=16418416 |doi=|url=http://www.annals.org/cgi/content/full/144/2/142]

Disclosing mistakes

Forgiveness, which is a part of many religions, may be important in coping with medical mistakes.cite journal |author=Berlinger N, Wu A |title=Subtracting insult from injury: addressing cultural expectations in the disclosure of medical error |journal=J Med Ethics |volume=31 |issue=2 |pages=106–8 |year=2005 |pmid=15681676 |doi=10.1136/jme.2003.005538]

Disclosure to oneself

Inability to forgive oneself may create a cycle of distress and increased likelihood of a future error.cite journal |author=West CP, Huschka MM, Novotny PJ, "et al" |title=Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study |journal=JAMA |volume=296 |issue=9 |pages=1071–8 |year=2006 |pmid=16954486 |doi=10.1001/jama.296.9.1071]

However, "...those who coped by accepting responsibility were more likely to make constructive changes in practice, but to experience more emotional distress."cite journal |author=Wu AW, Folkman S, McPhee SJ, Lo B |title=How house officers cope with their mistakes |journal=West. J. Med. |volume=159 |issue=5 |pages=565–9 |year=1993 |pmid=8279153 |doi=] 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."cite journal |author=Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W |title=Patients' and physicians' attitudes regarding the disclosure of medical errors |journal=JAMA |volume=289 |issue=8 |pages=1001–7 |year=2003 |pmid=12597752 |doi=] Detailed suggestions on how to disclose are available.cite journal |author=Wu AW, Cavanaugh TA, McPhee SJ, Lo B, Micco GP |title=To tell the truth: ethical and practical issues in disclosing medical mistakes to patients |journal=Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine |volume=12 |issue=12 |pages=770–5 |year=1997 |pmid=9436897 |doi=10.1046/j.1525-1497.1997.07163.x|url=http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=9436897]

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 Manualcite journal |author=Snyder L, Leffler C |title=Ethics manual: fifth edition |journal=Ann Intern Med |volume=142 |issue=7 |pages=560–82 |year=2005 |pmid=15809467] ::“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".cite journal |author=Kaldjian LC, Jones EW, Wu BJ, Forman-Hoffman VL, Levi BH, Rosenthal GE |title=Disclosing medical errors to patients: attitudes and practices of physicians and trainees |journal=Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine |volume=22 |issue=7 |pages=988–96 |year=2007 |pmid=17473944 |doi=10.1007/s11606-007-0227-z] Hospital administrators may share these concerns.cite journal |author=Weissman JS, Annas CL, Epstein AM, "et al" |title=Error reporting and disclosure systems: views from hospital leaders |journal=JAMA |volume=293 |issue=11 |pages=1359–66 |year=2005 |pmid=15769969 |doi=10.1001/jama.293.11.1359]

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"cite web |url=http://www.sorryworks.net/ |title=SorryWorks.net |accessdate=2007-08-16 |format= |work=]

Disclosure may actually reduce malpractice payments.cite journal |author=Wu AW |title=Handling hospital errors: is disclosure the best defense? |journal=Ann. Intern. Med. |volume=131 |issue=12 |pages=970–2 |year=1999 |pmid=10610651 |doi=] cite news |first= |last= |authorlink= |author=Zimmerman R |coauthors= |title=Doctors' New Tool To Fight Lawsuits: Saying 'I'm Sorry' |url=http://online.wsj.com/article/0,,SB108482777884713711,00.html |format= |work= |publisher=Dow Jones & Company, Inc |id= |pages= |page= |date=May 18, 2004 |accessdate=2007-08-16 |language= |quote= |archiveurl= |archivedate= ]

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 physicianscite journal |author=Sobecks NW, Justice AC, Hinze S, "et al" |title=When doctors marry doctors: a survey exploring the professional and family lives of young physicians |journal=Ann. Intern. Med. |volume=130 |issue=4 Pt 1 |pages=312–9 |year=1999 |pmid=10068390 |doi=] .

Disclosure to other physicians

Discussing mistakes with other doctors is beneficial.cite journal |author=Wu AW, Folkman S, McPhee SJ, Lo B |title=Do house officers learn from their mistakes? |journal=JAMA |volume=265 |issue=16 |pages=2089–94 |year=1991 |pmid=2013929 |doi=] 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."cite book |author=Oscar London |chapter=Rule 35: Don't Take Too Much Joy in the Mistakes of Other Doctors|title=Kill as few patients as possible: and fifty-six other essays on how to be the world's best doctor |publisher=Ten Speed Press |location=Berkeley, Calif |year=1987 |pages= |isbn=0-89815-197-X |oclc= |doi=]

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.cite journal |author=Barach P, Small SD |title=Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems |journal=BMJ |volume=320 |issue=7237 |pages=759–63 |year=2000 |pmid=10720361 |doi=] However, doctors report that institutions may not be supportive of the doctor.

References

External links

* [http://www.ahrq.gov/qual/errback.htm Medical Errors: The Scope of the Problem]
* [http://www.healthsentinel.com/org_news.php?event=org_news_print_list_item&id=088 Health Sentinel]


Wikimedia Foundation. 2010.

Игры ⚽ Поможем написать реферат

Look at other dictionaries:

  • Medical error — 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,… …   Wikipedia

  • Medical harm — According to the Cedars Sinai Elimination of Retained Foreign Object Task Force, 30% of objects accidentally left in the body as a result of surgery are surgical instruments.[1] Medical harm refers to any systemic failure in the health care… …   Wikipedia

  • Patient safety — is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often lead to adverse healthcare events. The frequency and magnitude of avoidable adverse patient events was not well known until the… …   Wikipedia

  • Pharmacy informatics — Definition of Pharmacy Informatics = Pharmacy informatics, also referred to as pharmacoinformatics, is the application of computers to the storage, retrieval and analysis of drug and prescription information. Pharmacy informaticists work with… …   Wikipedia

  • Bispectral index — A Bispectral index (BIS) monitor is a neurophysiological monitoring device which continually analyses a patient s electroencephalograms during general anaesthesia to assess the level of consciousness during anaesthesia. The depth of anaesthesia… …   Wikipedia

  • Computerized physician order entry — (CPOE) (also sometimes referred to as Computerized Provider Order Entry) is a process of electronic entry of medical practitioner instructions for the treatment of patients (particularly hospitalized patients) under his or her care. These orders… …   Wikipedia

  • The Leapfrog Group — The Leapfrog Group is an initiative driven by organizations that buy health care who are working to initiate breakthrough improvements in the safety, quality and affordability of healthcare for Americans. As a member supported program, The Leapf …   Wikipedia

  • Patient safety organization — A patient safety organization (PSO) 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 …   Wikipedia

  • Computer physician order entry — Computerized physician order entry (CPOE), is a process of electronic entry of medical practitioner instructions for the treatment of patients (particularly hospitalized patients) under his or her care. These orders are communicated over a… …   Wikipedia

  • Autopsy — Post mortem redirects here. For other uses, see Post mortem (disambiguation). This article is about the medical procedure. For other uses, see Autopsy (disambiguation). Autopsy Intervention The …   Wikipedia

Share the article and excerpts

Direct link
Do a right-click on the link above
and select “Copy Link”