Medical errors are a serious public health problem and a leading cause of death in the United States. It is challenging to uncover a consistent cause of errors and, even if found, to provide a consistent viable solution that minimizes the chances of a recurrent event. By recognizing untoward events occur, learning from them, and working toward preventing them, patient safety can be improved.
Part of the solution is to maintain a culture that works toward recognizing safety challenges and implementing viable solutions rather than harboring a culture of blame, shame, and punishment. Healthcare organizations need to establish a culture of safety that focuses on system improvement by viewing medical errors as challenges that must be overcome. All individuals on the healthcare team must play a role in making the provision of healthcare safer for patients and healthcare workers.
All providers know medical errors create a serious public health problem that poses a substantial threat to patient safety. Yet, one of the most challenging unanswered questions is "What constitutes a medical error?" The answer to this basic question has not been clearly established. Due to unclear definitions, “medical errors” are difficult to scientifically measure. A lack of standardized nomenclature and overlapping definitions of medical errors has hindered data analysis, synthesis, and evaluation.
There are two major types of errors:
Errors of omission occur as a result of actions not taken. Examples are not strapping a patient into a wheelchair or not stabilizing a gurney prior to patient transfer.
Errors of the commission occur as a result of the wrong action taken. Examples include administering a medication to which a patient has a known allergy or not labeling a laboratory specimen that is subsequently ascribed to the wrong patient.
Health care professionals experience profound psychological effects such as anger, guilt, inadequacy, depression, and suicide due to real or perceived errors. The threat of impending legal action may compound these feelings. This can also lead to a loss of clinical confidence. Clinicians equate errors with failure, with a breach of public trust, and with harming patients despite their mandate to “first do no harm.”
Fear of punishment makes healthcare professionals reluctant to report errors. While they fear for patients’ safety, they also dread disciplinary action, including the fear of losing their jobs if they report an incident. Unfortunately, failing to report contributes to the likelihood of serious patient harm. Many healthcare institutions have rigid policies in place that also create an adversarial environment. This can cause staff to hesitate to report an error, minimize the problem, or even fail to document the issue. These actions or lack thereof can contribute to an evolving cycle of medical errors. When these errors come to light, they can tarnish the reputation of the healthcare institution and the workers.
Some experts hold that the term “error” is excessively negative, antagonistic and perpetuates a culture of blame. A professional whose confidence and morale has been damaged as a result of an error may work less effectively and may abandon a career in medicine. Many experts suggest the term “error” should not be used at all. Due to the negative connotation, it is prudent to limit the use of the term “error” when documenting in the public medical record. However, adverse patient outcomes may occur because of errors; to delete the term obscures the goal of preventing and managing its causes and effects.
Errors, no matter the nomenclature, typically occur from the convergence of multiple contributing factors. Public and legislative intolerance for medical errors typically illustrates a lack of understanding that some errors may not, in fact, be preventable with current technology or the resources available to the practitioner. Human factors are always a problem, and identifying errors permits improvement strategies to be undertaken. In particular, blaming or punishing individuals for errors due to systemic causes does not address the causes nor prevent a repetition of the error. The trend is for patient safety experts to focus on improving the safety of health care systems to reduce the probability of errors and mitigate their effects rather than focus on an individual’s actions. Errors represent an opportunity for constructive changes and improved education in health care delivery.
Governmental, legal, and medical institutions must work collaboratively to remove the culture of blame while retaining accountability. When this challenge is met, health care institutions will not be constrained from measuring targets for process improvement, including all errors, even with adverse outcomes.
Healthcare providers want to improve outcomes while reducing the risk of patient harm. Despite provider best efforts, medical error rates remain high with significant disability and death. Preventable medical errors contribute substantially to healthcare costs, including higher health insurance costs per person expenses. Only by health professionals working together will the cost and injury associated with medical errors be mitigated.
The Joint Commission Patient Safety Goals
The Joint Commission has introduced several patient safety goals to assist institutions and healthcare practitioners in creating a safer practice environment for patients and providers. The Joint Commission Goals include:
Identify patient safety dangers and risks
Identify patients correctly by confirming the identity in at least two ways
Improve communication such as getting test results to the correct person quickly
Prevent infection by hand-cleaning, post-op infection antibiotics, catheter changes, and central line precautions.
Prevent mistakes in surgery by making sure the correct surgery is done on the correct body part; pause before surgery to double-check.
Use device alarms and make sure that alarms on medical equipment are heard and checked quickly.
Use medications correctly and safely, double-checking labeling and correctly passing on patient medicines to the next provider.
Label all medications, even those in a syringe. This should preferably be done in the area where the medications are prepared.
Take extra time with patients who have been prescribed anticoagulants and chemotherapeutic agents.
To prevent nosocomial infections, hand washing should be routine before and after visiting each patient.
Accountability
While it is true that individual providers should be held accountable for their decisions, there is a growing realization that the majority of errors are out of the clinician's control. This being said, it remains difficult to change a culture of non-reporting.
Questions to consider include:
The potential for errors in healthcare is very high. Due to cost control measures, are individuals accountable, or are increased workload and staff fatigue the reason for errors?
Why report? Failure to report errors may subject clinicians to disciplinary action and increased risk for legal liability. Beneficence and nonmaleficence are ethical concepts that are violated when an error is not reported.
Practitioners often fear they will gain a reputation for committing mistakes and may not self-report. They know that mistakes and written warnings are often recorded in personnel files. Does the system need modification to decrease the penalty and encourage reporting?
Punishment may, in fact, reduce reporting errors because of the discipline and humiliation that is associated with repeated errors. Nevertheless, not addressing the problem increases the potential for more adverse events which places more patients at risk. Rather than placing blame, administrators and review boards need to move toward eliminating the blame-shame-discipline structure and move toward a prevention and education structure.
This culture incorporates both learning and improvement efforts that target system redesign and a reporting culture whereby all providers feel safe from retribution and, therefore, report issues about safety that help to constantly improve patient care and improve the safety of the system.
Definitions
Patient safety has typically been outcome-dependent and the focus has been on preventing patients from experiencing adverse outcomes when receiving medical care. This may stem from Hippocrates, primum no nocere, or “First, do no harm.” While definitions in the literature are unclear, some general concepts can be garnered. Multiple similar definitions are available for each of these terms from various sources; the health practitioner should be aware of the general principles and probable meaning.
Active Error
Active errors are those taking place between a person and an aspect of a larger system at the point of contact.
Active errors are made by people on the front line such as clinicians and nurses. For example, operating on the wrong eye or amputating the wrong leg are classic examples of an active error.
Adverse Event
An adverse event is a type of injury that most frequently is due to an error in medical or surgical treatment rather than the underlying medical condition of the patient. Adverse events may be preventable when there is a failure to follow accepted practice at a system or individual level.
Not all adverse outcomes are the result of an error; hence, only preventable adverse events are attributed to medical error.
Adverse events can include unintended injury, prolonged hospitalization, or physical disability that results from medical or surgical patient management.
Adverse events can also include complications resulting from prolonged hospitalization or by factors inherent in the healthcare system.
Latent Error
These are errors in system or process design, faulty installation or maintenance of equipment, or ineffective organizational structure.
These are present but may go unnoticed for a long time with no ill effect.
When a latent error occurs in combination with an active human error, some type of event manifests in the patient. The active human error triggers the hidden latent error, resulting in an adverse event.
Latent errors are basically "accidents waiting to happen." A classic example is a hospital with several types of chest drainage sets, all requiring different connections and setups, yet not all frontline clinicians and nurses are familiar with the intricacies of each setup, creating the scenario for potential error.
Medical Error
The failure to complete the intended plan of action or implementing the wrong plan to achieve an aim.
An unintended act or one that fails to achieve the intended outcome.
Deviations from the process of care, which may or may not result in harm.
When planning or executing a procedure, the act of omission or commission that contributes or may contribute to an unintended consequence.
Negligence
Failure to meet the reasonably expected standard of care of an average, qualified healthcare worker looking after a patient in question within similar circumstances. For example, the healthcare worker may not check up on the pathology report which led to a missed cancer or the surgeon may have injured a nerve by mistaking it for an artery.
Negligent Adverse Events
A subcategory of preventable, adverse events that satisfy the legal criteria used in determining negligence.
The injury caused by substandard medical management.
Near Miss
Any event that could have had an adverse patient consequence but did not.
Potential adverse events that could have caused harm but did not, either by chance or because someone or something intervened.
Near misses provide opportunities for developing preventive strategies and actions and should receive the same level of scrutiny as adverse events.
Never Event
Never events are errors that should not ever have happened. A classic example of a never event is the development of pressure ulcers or wrong-site surgery. The National Quality Forum has identified the following as Serious Reportable Events:
Care Management
Device/Product
Environmental
Patient Protective
Surgical
Radiological
Noxious Episode
Untoward events, complications, and mishaps that result from acceptable diagnostic or therapeutic measures that are deliberately instituted. For example, sending a hemodynamically unstable trauma patient for prolonged imaging studies instead of the operating room. The result could be a traumatic arrest and death.
Patient Safety
The process of amelioration, avoidance, and prevention of adverse injuries or outcomes that arise as a result of the healthcare process.
Potentially Compensable Event
An error that could potentially lead to malpractice claims.
An event due to medical management that resulted in disability, and, subsequently, a prolonged hospitalization.
Root Cause
A deficiency or decision that, if corrected or avoided, will eliminate the undesirable consequence.
Common root causes include:
Changes in mental acumen including not seeking advice from peers, misapplying expertise, not formulating a plan, not considering the most obvious diagnosis, or conducting healthcare in an automatic fashion.
Communication issues, having no insight into the hierarchy, having no solid leadership, not knowing whom to report the problem, failing to disclose the issues, or having a disjointed system with no problem-solving ability.
Deficiencies in education, training, orientation, and experience.
Inadequate methods of identifying patients, incomplete assessment on admission, failing to obtain consent, and failing to provide education to patients.
Inadequate policies to guide healthcare workers.
Lack of consistency in procedures.
Inadequate staffing and/or poor supervision.
Technical failures associated with medical equipment.
No audits in the system.
No one prepared to accept blame or change the system.
Sentinel Event
The Joint Commission defines a "sentinel event" as “any unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof...The phrase 'or the risk thereof' includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.” (The Joint Commission, 2017). Sentinel events are so-called because once discovered, they frequently indicate the need for an immediate investigation, discovery of the cause, and response.
Extent of the Challenge
Approximately 400,000 hospitalized patients experience some type of preventable harm each year .
Depending on the study, medical errors account for over $4 billion per year.
Medical errors cost approximately $20 billion a year.
Medical errors in hospitals and clinics result in approximately 100,000 people dying each year.
Medical errors typically include surgical, diagnostic, medication, devices and equipment, and systems failures, infections, falls, and healthcare technology.
Missed diagnoses or injuries from medication are common in outpatient settings.
Most malpractice claims in hospitals are related to surgical errors, whereas most claims for outpatient care are related to missed or late diagnosis.
Slightly more than half of the paid malpractice claims are related to outpatient care.
To decrease overhead, hospitals often reduce nursing staff; staffing of RNs below target levels is associated with increased mortality.
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