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.

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.

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.

Causes

In medical trainees, contributing factors include errors in judgment and breakdowns in teamwork (including supervision).

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.

Personnel factors

Reduction of duty hours

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."

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." Previously, 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" which had been identified as likely to reduce medical error:

• Use of Rapid Response Teams, teams of critical care experts, at the first sign of potential problems. Hospitals which have applied this intervention often show a reduction in Code Blue calls. Code Blue is a call for emergency response to imminent death, usually cardiac arrest. Use of Rapid Response Teams has increased dramatically in U.S. Hospitals, from near zero in 2003 to 1500 in 2006.
• Prevention of certain types of common hospital-acquired infections, nosocomial infections. Infections often follow surgery, surgical site infections, insertion of central lines or use of ventilators, ventilator associated pneumonia. 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.

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

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.

The physician's perspective

Case reports review the strongly negative emotional impact of mistakes on the doctors who commit them.

Coping mechanisms

Essays and studies 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. There may be several breakdowns in processes to allow one adverse outcome. In addition, errors are more common when other demands compete for a physician's attention. 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 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.

Disclosure 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.

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." 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, 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.

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 physicians.

Disclosure 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.

Further Reading

• "The University of Texas Threat and Error Management Model:Components and Examples" PDF file Helmreich RL, Musson DM (link to BMJ is not good)
• Sexton JB et al.(2000) Error, stress, and teamwork in medicine and aviation: cross sectional surveys BMJ 320:745-9
• The Wikipedia article "Medical error" was consulted during the writing of this article and certain materials referenced in it were used.
• "Relationship between tort claims and patient incident reports in the Veterans Health Administration", article by J M Schmidek and W B Weeks, Qual Saf Health Care 2005;14:117-22 Shows incompleteness results even from a mandatory reporting system, "With a self-reporting system all reporting is voluntary."
• "Incident Reporting Systems in Medicine and Experience With the Aviation Safety Reporting System" Charles Billings, MD, "A Tale of Two Stories", National Patient Safety Foundation, Report from a Workshop on Assembling the Scientific Basis for Progress on Patient Safety
• "Adverse Events, Iatrogenic Injury and Error in Medicine"

Michael Edmonds, Health Informatics, The University of Adelaide, Last Modified Wednesday, 28-Jun-2006 11:32:06 CST, retrieved February 12, 2007

• Nancy Berlinger, After Harm: Medical Error And The Ethics Of Forgiveness, John Hopkins University Press (May, 2005), hardcover, 156 pages, ISBN 0801-88167-6
  • Review BMJ
• Janet Corrigan, Molla S. Donaldson, and Linda T. Kohn, editors, To Err Is Human: Building a Safer Health System, National Academy Press (April, 2000), hardcover, 287 pages, ISBN 0309-06837-1
  • Eight page summary (PDF file)
  • Searchable full text online
• Atul Gawande, Complications: A Surgeon's Notes on an Imperfect Science, ISBN 0-312-42170-2
• Committee on Quality of Health Care in America, Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century, National Academy Press (July, 2001), hardcover, 337 pages, ISBN 0309-07280-8
  • Searchable full text online
• Kathleen M. Sutcliffe, Marilynn M. Rosenthal, editors, Medical Error: What Do We Know? What Do We Do? John Wiley and Sons (July, 2002}, hardcover, 325 pages, ISBN 0787-96395-X
  • Review BMJ

External links

• University of Texas Human Factors Research Project
• AHRQ WebM&M (Morbidity and Mortality Rounds on the Web)
• "One Doctor's Crusade For Hospital Reform: Dr. Donald Berwick's Institute for Healthcare Improvement Hopes To Save Lives By Making Hospitals Safer" transcript, CBS Evening News, February 6, 2007
• “Status Quon’t”, IHI’s 2007 Progress Report (PDF file)

Previously published material

The material in Medical_errors#The_physician.27s_perspective has previously been published in Wikipedia at Preventable medical errors and is released under the GNU Free Documentation License.