Medical Error

Medical Error is preventable adverse effect of medical care, whether or not it is evident or harmful to the patient. (National Center of Biotechnology Information (NCBI)
An Error as an “unintended act (either Omission or Commission) or an act that does not achieve its intended outcome. (Dr. Lucian Leape, author of Error in Medicine)
The failure of planned action to be completed as intended, or as the use of a wrong plan to achieve an aim. (Institute of Medicine (IOM)
Definition of Medical Error

Medical Errors
Medical Errors represents a serious public health problem and pose a threat to patient safety.
Medical Errors can occur anywhere in the health care system
Patient harm from Medical Error can occur at the individual or system level.
Medical Errors can involve medicines, surgery, diagnosis, equipment or lab reports.

2 Types of Human Errors
Active Error- occur at the point of contact between a human and some aspect of a larger system (e.g., a human– machine interface). They are generally readily apparent (e.g., pushing an incorrect button, ignoring a warning light) and almost always involve someone at the frontline. Active failures are sometimes referred to as errors at the sharp end, figuratively referring to a scalpel. In other words, errors at the sharp end are noticed first because they are committed by the person closest to the patient.
According to the Health and Safety Executives (HSE)

2 Types of Human Errors
Latent Errors- refer to less apparent failures of organization or design that contributed to the occurrence of errors or allowed them to cause harm to patients. For instance, whereas the active failure in a particular adverse event may have been a mistake in programming an intravenous pump, a latent error might be that the institution uses multiple different types of infusion pumps, making programming errors more likely. Thus, latent errors are quite literally "accidents waiting to happen.
According to the Health and Safety Executives (HSE)

How common are Medical Errors?

Medical Errors…
A recent John Hopkins study claims more than 250,000 people in the U.S. die every year from Medical errors. Other reports claim the numbers to be as high as 440,000.
Medical errors are the third leading cause of death after heart disease and cancer.
The reason for discrepancy is that physicians, funeral directors, coroners and medical examiners rarely note on death certificates the human errors and system failures involved. Yet death certificates are what the Centers for Disease Control and Prevention rely on to post statistics for deaths

Some facts…
440, 000 patient die every year from preventable medical errors. (Journal of Patient safety)
Preventable medical errors cost USA tens of billions of dollars a year (Institute of Medicine)
One in three patients who are admitted to the hospital will experience a Medical Error (Health Affairs)
Evidence on Medical errors shows that 50% to 70.2% of such harm can be prevented through comprehensive systematic approaches to patient safety (Data & Statistics, WHO 2017)

Types of Medical Error
(Leape, Lucian; Lawthers, Ann G.; Brennan, Troyen A., et al. Preventing Medical Injury. Qual Rev Bull. 19(5):144–149, 1993.)

Most Common Medical Errors
Misdiagnosis
Delayed Diagnosis
Medication Error (most common)
Faulty Medical Devices
Infection (CLABSI, SSI, CAUTI etc.)
Failure to account for surgical equipment
Improper Medical Devices placement

8 Common Root Causes of Medical Errors
Communication Problems (Verbal/Written)
Inadequate Information Flow
Human Problems
Patient Related Issues
Organizational Transfer of Knowledge
Staffing Patterns and Workflow
Technical Failures
Inadequate Policies
http://www.hopkinsmedicine.org/news/media/releases/study_suggests_medical_errors_now_third_leading_cause_of_death_in_the_us?preview=true

Prevention of Medical Errors
Error prevention measures include:
Reduce reliance on memory
Improved Information access
Error-proofing systems
Standardization
Training on error identification and prevention
Examples in Medical Practice
Checklist, Flowsheets
Electronic Medical Records
Fail-safe to avoid prescribing 2 drugs that interact fatally
Office Formularies, Guidelines
Orientation of Staff in services

MEDICAL ERROR REPORTING

All providers (nurses, pharmacists, and physicians) must accept the inherent issues in their roles as healthcare workers that contribute to error-prone environments.
Effective communication related to medical errors may foster autonomy and ultimately improve patient safety.
Error reporting better serves patients and providers by mitigating their effects.
Even the best clinicians make mistakes, and every practitioner should be encouraged to provide peer support to their colleagues after an adverse event occurs.
Importance of Medical Error Reporting

Medical errors and near misses should be reported when they are discovered. Healthcare professionals are usually the first to notice a change in a patient's condition that suggests an adverse event. A cultural approach in which personal accountability results in long-term increased reporting reduces errors.
(Medical error prevention (5 May 2020)

Simplified Flow OVR process

OCCURRENCE VARIANCE REPORT

We learn most from our painful mistakes. Mistakes can injure patients and land physicians in legal and professional trouble. Studying these mistakes and learning how to prevent, monitor, and respond to them, however, has changed the standards of care.

In 1976, Dr. Jim Styner, an orthopedic surgeon, crashed his small plane into a cornfield in Nebraska, sustaining serious injuries. His wife was killed, and 3 of their 4 children were critically injured. At the local hospital, the care that he and his children received was inadequate, even by standards in those days
His family's tragedy and the medical mistakes that followed gave birth to Advanced Trauma Life Support (ATLS) and changed the standard of care in the first hour after trauma.

Judy was 39 years old when she went to the hospital for a hysterectomy. After she died on the operating table, autopsy revealed that the anesthesiologist had placed the endotracheal tube in her esophagus, not her trachea.
Today, anesthesiologists measure a patient's carbon dioxide levels -- which are much higher from the trachea than from the esophagus -- through use of an end-tidal carbon dioxide monitor.
Standard practices now include the use of pulse oximetry and end-tidal carbon dioxide monitoring for anesthetized patients. The new standards have markedly reduced the frequency of anoxic brain injury and other major complications.

Sally and Ed looked forward to the birth of their first child. Sally's labor was long, so her obstetrician added oxytocin to speed things up. Unfortunately, administration of oxytocin led to unrecognized fetal distress, and their newborn daughter suffered severe brain injury and cerebral palsy.
Fetal monitoring to test both uterine contractions and fetal heart rate (FHR) is now the standard of care, with a 30-minute response time from recognition of fetal distress to delivery. The purpose of FHR monitoring is to follow the status of the fetus during labor so that clinicians can intervene if there is evidence of fetal distress

Preventing wrong-site surgery became one of the main safety goals of the Joint Commission for Accreditation of Healthcare Organizations (JCAHO). Establishing protocols became an accreditation requirement for hospitals, ambulatory surgery centers, and office-based surgery sites.
Bill had a seizure and crashed his car into a tree, crushing both legs. Arteriography revealed that his right leg was salvageable but his left leg was not. Unfortunately, the x-ray technician mislabeled the films, mixing left for right, and the orthopedic surgeon first amputated Bill's right leg.

Tom was 12 years old when his appendix burst and he was taken to the local pediatric hospital. Three days after the appendectomy, he developed another high fever. One week later, the surgeon performed a second procedure and found that a surgical sponge had been left inside.
Different ways of counting sponges may be used in the same operating room even during the same case, says the Association of Operating Room Nurses. This lack of standardized practice creates opportunities for errors
Nursing and surgical groups recommend that each member of the surgical team play an equal role in assuring accuracy of the counts. Recently, manufacturers have made sponges with threads visible on x-rays, radiofrequency identification systems, and bar coding to alert staff about missing sponges.

As a young child, Betty had been given penicillin, turned blue, and was rushed to the hospital. She was 15 when she got strep throat, was given penicillin, and died. No one had asked her about medication allergies.
Medical questionnaire forms have always included a space for allergies, although this became much more prominent after the Institute of Medicine report on patient safety in 1999.
Strategies to address the problem include adding visible prompts in consistent and prominent locations listing patient allergies, eliminating the practice of writing drug allergens on allergy arm bracelets, and making the allergy reaction selection a mandatory entry in the organization's order-entry systems.

Linda wasn't doing well in her first trimester. The nausea and vomiting left her severely dehydrated and with a low potassium level. In the emergency department, her nurse made a mathematical error and administered too much intravenous potassium. Within an hour, Linda was dead.
In the 1980s and 1990s, patient safety groups, including JCAHO, drew attention to the need for removal of concentrated potassium chloride vials from patient care areas.
Additional safety strategies include using premixed solutions, segregating potassium from other drugs and using warning labels, prohibiting the dispensing of vials for individual patients, and performing double-checks with a pharmacist.

Frank was 72 years old when he broke his right leg in a car accident and had to recover for a few weeks in a rehabilitation facility. The nurses didn't know that patients needed to move regularly, and Frank developed deep decubitus (pressure) ulcers. When these became infected, Frank's leg had to be amputated.
Nursing homes and hospitals now have programs to avoid development of bedsores by using a set timeframe to reduce pressure and having dry sheets by using catheters or impermeable dressing. Pressure shifting on a regular basis and the use of pressure-distributive mattresses are now common practices.

Lillian was 68 years old and weighed 250 lb when she underwent surgery to remove her gallbladder. The second day after surgery, she needed help to walk to the bathroom. Lillian's nurse, Millie, wasn't strong enough to support her and they both fell, breaking Millie's right arm and Lillian's left leg.
The ANA supports policies that eliminate manual patient lifting. Safe patient-handling techniques involve the use of such equipment as full-body slings, stand-assist lifts, lateral transfer devices, and friction-reducing devices.

When Christy was 42 years old, her doctor discovered a large lump in her left breast. The lump should have been evident during Christy's 2 previous annual examinations if they had been complete. By the time it was diagnosed, the cancer had progressed beyond cure.
Breast examinations by the physician, teaching of techniques for breast self-examination, and recommendation of mammograms are now the standard of care.