Medical Errors

1
Medical Errors

• Frances Symons
• PHE 570

2
Definition- Medical Error

• Failure of a planned action to be completed as
  intended or the use of a wrong plan to achieve an
  aim.
• For example an adverse drug event, improper
  transfusion, surgical injuries and wrong site
  injuries, suicide, restraint-related injury or
  death, falls, burns, pressure ulcers and mistaken
  patient identity.
• At least 44,000- 98,000 people die in hospitals
  each year from preventable medical errors.
  (Institute of Medicine, 1999)

3
Background

• Before the 1990s- perfect performance was
  expected and felt to be achievable through
  education, professionalism, vigilance and care
• Lead to fear of retribution and drove errors
  underground
• Mid 1990s- providers were starting to
  acknowledge human fallibility and the impossible
  task of perfect performance
• Did not confront individuals who willfully made
  unsafe choices and put the patient at risk
• (Institute for Safe Medication Practices,
  2006)

4
Costs of a Medical Error

• IOM in 1999 issued a report estimating total
  costs (including the expense of additional care
  necessitated by the errors, lost income and
  household productivity, and disability) of
  between 17 billion and 29 billion per year in
  hospitals nationwide.
• Medication Errors
• each preventable adverse drug event that took
  place in a hospital added about 8,750 (2006
  dollars) to the cost of a hospital stay.
• 400,000 of these events occur each year
• (IOM, 2006)

5
After an Error Occurs

• Patient faces a lack of productivity, loss of
  quality of life, depression, traumatization and
  may increase their fear of an error in the
  future.
• What about the health care provider?
• Physicians felt upset and guilty about harming
  the patient, disappointed about failing to
  practice medicine to their own high standards,
  fearful about a possible lawsuit and anxious
  about the errors repercussions regarding their
  reputation (Gallagher et al., 2003).
• Physicians struggle with forgiving themselves for
  what happened and some turned to a trusted
  colleague, significant other or the affected
  patient to seek forgiveness through disclosure
  (Gallagher et al., 2003).

6
Disclosure of an Error

• In aviation it is not merely the pilot who is
  responsible for the outcomes of a flight it is
  the pilot, the air traffic controllers, the
  maintenance crew, the stewards, and the ground
  staff-in other words, the aviation system. Thus,
  neither the last person to touch the controls nor
  the last person to touch the patient is fully and
  solely responsible for the outcome, good or bad
  (Liang, 2002).
• Blame for a medical error can not be placed on
  one person

7
Disclosure

• There is a broad definition of a medical error by
  both providers and patients, the process of
  disclosing an error is even more muddled.
• Physicians say their worst fear about errors
  included lawsuits, loss of patient trust, the
  patient informing friends about their bad
  experience, loss of colleagues respect, and
  diminished self-confidence (Gallagher et al.,
  2003).
• Patients believed the error disclosure would
  improve their trust in their providers honesty
  and would reassure them that they were receiving
  complete information about their overall care
  (Gallagher et al., 2003).

8
Disclosure

• Physicians while striving to be truthful, were
  reluctant to provide patients with basic
  information concerning their error (Gallagher et
  al., 2003).
• The fear of confession is appropriate concerning
  the shame and blame still pervasive within the
  healthcare system and could imply fault.

9
Fixing Healthcare

• All healthcare schools should educate about
  medical errors
• Prevention
• Disclosure
• Understanding themselves
• Emotional support needs to be available
• Clear definition of medical error
• Basis for reporting across America
• Make reporting mandatory
• Use and error investigation team

10
Questions?

• What are your recommendations for the healthcare
  system?

11
Websites of Interest

• Agency for Health Care Research and Quality
  http//www.ahrq.gov/
• Oregon Patient Safety Commission
  http//www.oregon.gov/OPSC/index.shtml