Preventable medical error

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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.

Contents 1 Nature and extent 1.1 Difficulties in measuring frequency of errors 2 Most common causes 3 Medical errors and medical malpractice 4 Most common preventable medical errors leading to malpractice 5 The physician's perspective 5.1 Coping mechanisms 5.1.1 Recognizing that mistakes are not isolated events 5.1.2 Placing the practice of medicine in perspective 5.1.3 Disclosing mistakes 5.1.3.1 Disclosure to oneself 5.1.3.2 Disclosure to patients 5.1.3.3 Disclosure to non-physicians 5.1.3.4 Disclosure to other physicians 5.1.3.5 Disclosure to the physician's institution 6 References 7 External links

[edit] 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. ^[1]

• 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.^[2]
• 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'^[3]

[edit] Difficulties in measuring frequency of errors

Althougt about 1% of hospital admissions have an adverse event due to negligence ^[4], 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 manifestations^[5]. Even this number may be an underestimate. One study suggests that in the United States adults only receive 55% of recommended care ^[6] while at the same time a second study found that 30% of care in the United States may be unnecessary ^[7]. For example, if a doctor fails to order a mammogram that is past due, this mistake will not show up in the first study^[4] because no adverse event occurred during the short follow up of the study, the mistake would also not show up in the second study^[5] 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.

[edit] 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. ^[8]

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

[edit] 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. ^[9]

[edit] 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.

[edit] The physician's perspective

Case reports review the strongly negative emotional impact of mistakes on the doctors who commit them.^{[10][11][12][13]}

[edit] Coping mechanisms

Essays^[14] and studies^[15][16] have described physician coping mechanisms.

[edit] 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.^[17] There may be several breakdowns in processes to allow one adverse outcome. ^[18] In addition, errors are more common when other demands compete for a physician's attention.^[19][20][21] However, placing too much blame on the system may not be constructive.^[17]

[edit] 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"^[22]
• "... 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."^[23]

[edit] Disclosing mistakes

Forgiveness, which is a part of many religions, may be important in coping with medical mistakes.^[24]

[edit] Disclosure to oneself

Inability to forgive oneself may create a cycle of distress and increased likelihood of a future error.^[25]

However, "...those who coped by accepting responsibility were more likely to make constructive changes in practice, but to experience more emotional distress."^[26] It may be helpful to consider the much larger number of patients who are not exposed to mistakes and are helped by medical care.^[23]

[edit] 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."^[27] Detailed suggestions on how to disclose are available.^[28]

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^[29]:

“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".^[30] Hospital administrators may share these concerns.^[31]

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"^[32]

Disclosure may actually reduce malpractice payments.^[33][34]

[edit] 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^[16]. 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].

[edit] Disclosure to other physicians

Discussing mistakes with other doctors is beneficial.^[17] 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]

[edit] 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.^[17]

[edit] References

[edit] External links

• Medical Errors: The Scope of the Problem
• Health Sentinel