Patient Safety and Medical Errors

1
Patient Safety and Medical Errors

• Family Medicine Clerkship
• New York Medical College
• 2003 2004
• Joseph L. Halbach, MD, MPH

2
Patient Safety and Medical Errors

• Todays Discussion
• Errors/Mistakes in general
• Responses to mistakes
• One brief description of a medical error
• What responsible physicians experience after an
  error
• Brief data on medical errors
• Whats the problem
• What to do as a medical student

3
Patient Safety and Medical Errors

• Non-Medical Mistake
• Think about a recent error or mistake that you
  made.
• What was your reaction to making that mistake?

4
Jose MartinezfromThe New York Times Magazine
Patient Safety and Medical Errors
5
The emotional impact of mistakes on family
physicians. Newman 1996
Patient Safety and Medical Errors

• 30 family physicians interviewed by a family
  physician.
• Memorable mistake
• Response to a hypothetical scenario in which a
  colleagues decision was associated with a fatal
  outcome

6
Patient Safety and Medical Errors

• 24/30 30-50 years old
• 26/30 male
• 26/30 married
• 27/30 white

• 23/30 remembered a mistake
• 5/30 unable to remember a mistake
• 2/30 had never made a mistake

7
Memorable mistake
Patient Safety and Medical Errors

• 18/23 family physicians who remembered making a
  mistake made their most memorable mistake post
  residency
• Remembered mistakes occurred almost as often in
  their offices as in the hospital.

8
Reactions
Patient Safety and Medical Errors

• 96 reported self doubt
• 93 were disappointed in themselves
• 86 blamed themselves for the mistake
• 54 experienced shame
• 50 experienced fear

9
Support?
Patient Safety and Medical Errors

• In response to their mistakes, all but one
  physician stated a need for support.
• 63 needed to talk to someone
• 48 needed validation of their decision making
  process
• 59 needed reaffirmation of their professional
  competency
• 30 needed reassurance of self worth

10
Source of support?
Patient Safety and Medical Errors

• 55 spouse
• 33 colleague

11
Hypothetical scenario
Patient Safety and Medical Errors

• A colleague of yours recently saw a 54-year-old
  man in his office who was complaining of burning
  epigastric and lower retrosternal chest pain
  without radiation or other associated symptoms
  about an hour after lunch. In the office, the
  EKG showed some unifocal PVCs and some
  non-specific ST-T wave changes. After evaluating
  his patients condition, your colleague
  recommended that he take an antacid and return to
  the office in one week. Later that night, the
  patient was taken to the ER, unconscious, in V
  fib. The following morning, word has gotten
  around about how this attending physician missed
  an obvious and fatal MI. On making rounds, you
  see your colleague at the nurses station.

12
Patient Safety and Medical Errors

• All but one family physician thought that their
  colleague needed support.
• Nine (32) would have offered support
  unconditionally
• 19 (68) would have offered support if
• He/she were a close friend or partner
• He/she first solicited their support

13
Epidemiology of medical errors
Patient Safety and Medical Errors

• Incomplete picture
• 1984 Harvard Medical Practice study
• 1999 Colorado/Utah study
• 1999 report of the Institute of Medicine To Err
  Is Human

14
Patient Safety and Medical Errors

• IOM reports 44,000-98,000 Americans die in
  hospitals each year as a result of medical
  errors.
• 8th leading cause of death (surpassing MVAs,
  breast cancer, AIDS).
• 6 of national health care expenditures (1996).
• 7000 deaths from medication errors alone (1993).

15
Patient Safety and Medical Errors

• Whats the PROBLEM(S)?
• (e.g., in the Jose Martinez case)

16
Patient Safety and Medical Errors

• What would help to PREVENT ERRORS?
• Are there any RULES/REGULATIONS about what we
  should do/have to do?

17
Patient Safety and Medical Errors

• What to do as a medical student?
• - M and M on the Web
• www/webmm.ahrq.gov

18
(No Transcript)
19
(No Transcript)
20
(No Transcript)
21
Patient Safety and Medical Errors

• What to do as a medical student
• JCAHO National Patient Safety Goals
• 1 Patient Identification
• 2 Abbreviations
• 3 Wrong site, wrong patient, wrong procedure

22
Patient Safety and Medical Errors

• Summary

• Mistakes happen to everyone.
• Good doctors make bad mistakes.
• When we make an error, we need support.
• Most errors result from system problems.
• Open reporting and disclosure, not shame and
  blame.
• Stayed informed!