Medical Error

1
Medical Error

• Introduction and terminology

2
Medical Errors

• Wayne Jowett, died at Feb. 2001 at Queen's
  Medical Centre, Nottingham, after the cytotoxic
  drug vincristine, intended for intravenous
  injection, was instead injected into his spine.

• 14 patients had died or been left paralyzed as a
  result of similar errors in the past 15 years.

3
Medical Errors

• Professor Brian Toft, an accident investigator,
  identified 48 separate factors as contributing to
  the tragedy
• The injection was performed by a senior house
  officer who had been on the ward for five weeks
• He was supervised by another clinician who worked
  as a specialist registrar for only three days.
• Vincristine was brought to the ward at the same
  time as the intrathecal drug cytosine.
• syringes containing vincristine could also be
  connected to the spinal needles that delivered
  intrathecal drugs to patients.

4
Medical Errors

• Dr Chapman said that Wayne Jowett had been let
  down by medical, nursing, and pharmacy staff the
  hospital had let down medical teams by not
  training them properly and there were "also
  questions for the drug industry and the
  Department of Health."

5
To Err Is Human

• Human beings, even well intentioned
  ones,
• will invariably make errors in a complex system

6

• We are the first species to have taken our
  evolution into our own hands
• Carl Sagan

7
Human error

• Terminology

8
Error

• Failure of a planned action to be completed as
  intended (error of execution)
• or use of a wrong plan to achieve an aim (error
  of planning)
• the accumulation of errors results in accident.

9
Accident

• An error that involves damage to a defined system
  that disrupt the ongoing or future output of
  system.

10
Slip Errors

• An error of execution when the action conducted
  was not that was intended the wrong action is
  observable

11
Lapse Error

• An error of execution when the action conducted
  was not that was intended the wrong action is
  not observable.

12
Mistake (Error of Planning)

• An error in which the action proceeds as planned
  but fails to achieve intended outcomes because
  the planned action was wrong

13
Error
Error of Execution
Error of Planning (Mistake)
Lapse Error
Slip Error
Observable Error
Un-Observable Error
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14
Active Error

• An error that occurs at the level of the
  frontline operator and whose effects are felt
  almost immediately

15
Latent Error

• Errors in the design organization, training, or
  maintenance that lead to operator errors and
  whose effects typically lie dormant in the system
  for lengthy periods of time

16
Error
Latent Error
Active Error
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17
Events can be classified in three different
categories

• Sentinel event or misadventure
• No-harm event
• Near miss

18
Error
No Harm Event
Near Miss
Sentinel Event

• A sentinel event or misadventure is an event in
  which death or harm to a patient or harm to the
  mission of the organization has occurred.

19
Error
No Harm Event
Near Miss
Sentinel Event

• Events that have occurred but resulted in no
  actual harm although the potential for harm may
  have been present. Lack of harm may be due to the
  robust nature of human physiology or pure luck

20
Error
No Harm Event
Near Miss
Sentinel Event

• A near miss, is an event in which the unwanted
  consequences were prevented because there was a
  recovery by identification and correction of the
  failure, either planned or unplanned.

21
Error
No Harm Event
Near Miss
Sentinel Event
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22
Adverse Event

• An injury resulting from a medical intervention.
• May be called Averted event.

23
Adverse Event
Unpreventable Adverse Event
Preventable Adverse Event

• An injury that occurs as a result of medical
  error with standard medical care the injury
  would not have occurred.

24
Adverse Event
Unpreventable Adverse Event
Preventable Adverse Event
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25
Omission vs. Commission

• An error of omission is a failure of action, such
  as a missed diagnosis, a delayed evaluation, or a
  failure to prescribe needed drug treatment.
• An error of commission is an incorrect action,
  such as administering the wrong drug to the wrong
  patient at the wrong time.
• In the Australian study, errors of omission
  outnumbered errors of commission by 2 to 1.

26
Adverse Outcomes

• Undesirable and unintended outcomes of care such
  as death, disability, or temporary disability.

27
Hazard

• Anything that can cause harm.

28
Dangerous Situations

• Where both human and latent failure exist that
  create a hazard increasing the risk of harm, this
  is a dangerous situation.

29
Risk

• The likelihood that somebody or something will be
  harmed by a hazard, multiplied by the severity of
  the potential harm.

30
Patient Safety

• Freedom from accidental injury ensuring patient
  safety involves the establishment of operational
  systems and processes that minimize the
  likelihood of errors and maximize the likelihood
  of intercepting them when they occur.

31
Quality of Care

• Degree to which health services for individuals
  and populations increase the likelihood of
  desired health outcomes and are consistent with
  current professional knowledge.

32
System

• A set of interdependent elements interacting to
  achieve a common aim.

33
Positive Sentinel Events

• Information may be collected about situations in
  which a patients care is unexpectedly
  successful, and investigations may lead to
  discoveries about why other patients care does
  not go as smoothly.