Medical error: Difference between revisions

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'''Medical errors''' are mistakes made in a medical setting. [[Error]]s are made by every health care worker in every hospital and health care facility. The reason is straightforward: in any human system, error can occur and therefore, eventually, does occur. The incidence of error in medical care can be reduced, but never totally eliminated. When an error occurs, the question becomes, will it be recognized and corrected? Most errors that result in injury involve subsequent errors of not recognizing that an error has occurred and not taking remedial action. "In 2001, the U.S. Institute of Medicine estimated the risks of medical error-related deaths in the United States to be 44,000–98,000 deaths per year, letting aside other serious adverse events". <ref>[http://www.nap.edu/openbook/0309068371/html/1.html Page 1, ''To Err Is Human: Building a Safer Health System''], Janet Corrigan, Molla S. Donaldson, and Linda T. Kohn, editors,  National Academy Press (April, 2000), hardcover, 287 pages, ISBN 0309-06837-1</ref>
'''Medical errors''' are mistakes made in a medical setting. [[Error]]s are made by every health care worker in every hospital and health care facility. The reason is straightforward: in any human system, error can occur and therefore, eventually, does occur. The incidence of error in medical care can be reduced, but never totally eliminated. When an error occurs, the question becomes, will it be recognized and corrected? Most errors that result in injury involve subsequent errors of not recognizing that an error has occurred and not taking remedial action. "In 2001, the U.S. Institute of Medicine estimated the risks of medical error-related deaths in the United States to be 44,000–98,000 deaths per year, letting aside other serious adverse events". <ref>[http://orsted.nap.edu/openbook/0309068371/gifmid/1.gif Page 1, ''To Err Is Human: Building a Safer Health System''], Janet Corrigan, Molla S. Donaldson, and Linda T. Kohn, editors,  National Academy Press (April, 2000), hardcover, 287 pages, ISBN 0309-06837-1</ref>
   
   
==Malpractice==
==Malpractice==

Revision as of 13:25, 16 February 2007

Medical errors are mistakes made in a medical setting. Errors are made by every health care worker in every hospital and health care facility. The reason is straightforward: in any human system, error can occur and therefore, eventually, does occur. The incidence of error in medical care can be reduced, but never totally eliminated. When an error occurs, the question becomes, will it be recognized and corrected? Most errors that result in injury involve subsequent errors of not recognizing that an error has occurred and not taking remedial action. "In 2001, the U.S. Institute of Medicine estimated the risks of medical error-related deaths in the United States to be 44,000–98,000 deaths per year, letting aside other serious adverse events". [1]

Malpractice

If an error involves negligence, as legally defined, and results in injury, 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.

On-going strategies for reduction of medical error

Lessons from aviation

Plane crashes are often spectacular and well publicized, resulting sometimes in significant loss of life. Consequently all plane crashes and other serious incidents are exhaustively investigated and analyzed with respect to cause. On the other hand, most medical errors do not have the same spectacular effects, thus do not usually receive the same intense scrutiny and analysis. [2]

Adaptation of a "pilot's checklist" to prepare for take-off and landing has been tested for use for usefulness in preparation for the performance of Cesarean delivery under general anesthesia. [3]

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." [4]

oversight of professional conduct

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 6 "interventions" which had been identified as likely to reduce medical error:

  1. 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 cardiac arrest. Use of Rapid Response Teams has increased dramatically in U.S. Hospitals, from near zero in 2003 to 1500 in 2006. [5]

IHI's second campaign, the 5 Million Lives Campaign, [6] challenges 4,000 hospitals to adopt at least one of twelve interventions: the six original interventions and six more. [7] 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. [8]

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



Notes

  1. ↑ Page 1, To Err Is Human: Building a Safer Health System, Janet Corrigan, Molla S. Donaldson, and Linda T. Kohn, editors, National Academy Press (April, 2000), hardcover, 287 pages, ISBN 0309-06837-1
  2. ↑ "On error management: lessons from aviation" article by Robert L Helmreich, BMJ 2000;320:781-785 ( 18 March )
  3. ↑ Hart EM. Owen H. "Errors and omissions in anesthesia: a pilot study using a pilot's checklist", Journal Article. Research Support, Non-U.S. Gov't, Anesthesia & Analgesia, 101(1):246-50, table of contents, 2005 Jul., UI: 15976240
  4. ↑ Myers, Jennifer S. MD; Bellini, Lisa M. MD; Morris, Jon B. MD; Graham, Debra MD; Katz, Joel MD; Potts, John R. MD; Weiner, Charles MD; Volpp, Kevin G. MD, PhD, Internal medicine and general surgery residents' attitudes about the ACGME duty hours regulations: a multicenter study, Academic Medicine 81(12):1052-8, 2006 Dec. UI: 17122468
  5. ↑ “Status Quon’t”, IHI’s 2007 Progress Report (PDF file)
  6. ↑ 5 Million Lives Campaign
  7. ↑ "Overview of the 5 Million Lives Campaign"
  8. ↑ "IHI Launches National Initiative to Reduce Medical Harm in U.S. Hospitals, Builds on 100,000 Lives Campaign" Infection Control Today, December 12, 2006

References

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

Further Reading

External links

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