Medical error
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:
- 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
- ↑ Assadian, Ojan MD, DTMH; Toma, Cyril D. MD; Rowley, Stuart D., "Implications of staffing ratios and workload limitations on healthcare-associated infections and the quality of patient care", Critical Care Medicine 35(1):296-8, 2007 Jan. UI: 17197771
- ↑ "On error management: lessons from aviation" article by Robert L Helmreich, BMJ 2000;320:781-785 ( 18 March )
- ↑ 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
- ↑ 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
- ↑ “Status Quon’t”, IHI’s 2007 Progress Report (PDF file)
- ↑ 5 Million Lives Campaign
- ↑ "Overview of the 5 Million Lives Campaign"
- ↑ "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
- "The University of Texas Threat and Error Management Model:Components and Examples" PDF file Robert L. Helmreich and David M. Musson (link to BMJ is not good)
- "Error, stress, and teamwork in medicine and aviation: cross sectional surveys" paper by J Bryan Sexton, Eric J Thomas, and Robert L Helmreich, BMJ 2000;320:745-749 ( 18 March )
- 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;14:117-122 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
Further Reading
- Nancy Berlinger, After Harm: Medical Error And The Ethics Of Forgiveness, John Hopkins University Press (May, 2005), hardcover, 156 pages, ISBN 0801-88167-6
- 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
- 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
- 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
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)