Medical error

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In the United States medical error is estimated to result in 44,000 to 98,000 unnecessary deaths and 1,000,000 excess injuries each year.[1][2]. One older extrapolation suggests '180,000 people die each year partly as a result of iatrogenic injury, the equivalent of three jumbo-jet crashes every 2 days'[3]. It is estimated that in a typical 100 to 300 bed hospital in the United States, excess costs of $1,000,000 to $3,000,000 attributable to prolonged stays and complications just due to medication errors occur yearly.

However, medical error definitions are subject to debate, as there are many types of medical error from minor to major,[4] and causality is often poorly determined.[5] The Health Grades study statistics, based on AHRQ MedPAR data, were based on administrative records, not clinical records, and largely overlooked multi-causality of outcomes.[6]

Medical care is frequently compared adversely to aviation, in that, while many of the factors which lead to error are similar, aviation's error management protocols are much more effective.[7]

Contents

[edit] Epidemiology of medical error

Medical errors are associated with inexperienced clinicians, new procedures, extremes of age, complex care and urgent care.[8] Poor communication (whether in ones own language or, as may be the case for medical tourists, another language), improper documentation, illegible handwriting, inadequate nurse-to-patient ratios, and similarly named medications are also known to contribute to the problem. Patient actions may also contribute significantly to medical errors. Falls, for example, are often due to patients' own misjudgements.

Sleep deprivation has also been cited as a contributing factor. One study found that being awake for over 24 hours caused medical interns to double or triple the number of preventable medical errors, including those which resulted in injury or death. .[9] The risk of car crash after these shifts increased by 168%, and the risk of near miss by 460%.[10] Interns admitted falling asleep during lectures, during rounds, and even during surgeries.[10]

[edit] Approaches to error

Main article: Preventable medical errors

Traditionally, errors are attributed to mistakes made by individuals who may be penalized for these mistakes. The usual approach to correct the errors is to create new rules with additional checking steps in the system, aiming to prevent further errors. As an example, an error of free flow IV administration of heparin is approached by teaching staff how to use the IV systems and to use special care in setting the IV pump. While overall errors become less likely, the checks add to workload and may in themselves be a cause of additional errors.

A newer model for improvement in medical care takes its origin from the work of W. Edwards Deming in a model of Total Quality Management. In this model, there is an attempt to identify the underlying system defect that allowed the opportunity for the error to occur. As an example, in such a system the error of free flow IV administration of Heparin is dealt with by not using IV heparin and substituting subcutaneous administration of heparin, obviating the entire problem. However, such an approach presupposes available research showing that subcutaneous heparin is as effective as IV. Thus, most systems use a combination of approaches to the problem.

The field of medicine that has taken the lead in systems approaches to safety is anaesthesiology.[11] Steps such as standardization of IV medications to 1 ml doses, national and international color coding standards, and development of improved airway support devices has made anesthesia care a model of systems improvement in care.

The profession of pharmacy has extensively studied the causes of errors in the prescribing, preparation, dispensing and administration of medications. As far back as the 1930’s, pharmacists worked with physicians to select from many options, the safest and most effective drugs available for use in hospitals [12]. The process is known as the Formulary System and the list of drugs is known as the Formulary. In the 1960’s, hospitals implemented unit dose packaging and unit dose drug distribution systems to reduce the risk of wrong drug and wrong dose errors in hospitalized patients[13]; centralized sterile admixture services were shown to decrease the risks of contaminated and infected intravenous medications[14]; pharmacy computers screened each patient’s medication list for drug-drug interactions[15]; and, pharmacists provided drug information and clinical decision support directly to physicians to improve the safe and effective use of medications[16]. Pharmacists are recognized experts in medication safety and have made many contributions that reduce error and improve patient care over the last 50 years.

A 2005 study by Wendy Levinson of the University of Toronto showed surgeons discussing medical errors used the word "error" or "mistake" in only 57 per cent of disclosure conversations and offered a verbal apology only 47 per cent of the time.[17]

[edit] Misdiagnosis of psychological disorders

Sufferers of dissociative identity disorder usually have psychiatric histories that contain three or more separate mental disorders and previous treatment failures.[18] The disbelief of some doctors around the validity of dissociative identity disorder may also add to its misdiagnosis.[18] Studies have found that bipolar disorder has often been misdiagnosed as major depression. Its early diagnosis necessitates that clinicians pay attention to the features of the patient's depression and also look for present or prior hypomanic or manic symptomatology.[19] The misdiagnosis of schizophrenia is also a common problem. There may be long delays of patients getting a correct diagnosis of this disorder. [20]

[edit] Examples of errors

  1. Misdiagnosis
  2. Giving the wrong drug or (wrong patient, wrong chemical, wrong dose, wrong time, wrong route)
  3. Giving two or more drugs that interact unfavorably or cause poisonous metabolic byproducts
  4. Wrong site surgery such as amputating the wrong limb

[edit] Methods to improve safety and reduce error

Main article: Patient safety
  1. patient's informed consent policy
  2. patient's getting a second opinion from another independent practitioner with similar qualifications
  3. voluntary reporting of errors (to obtain valid data for cause analysis)
  4. root cause analysis
  5. Electronic or paper reminders to help patients maintain medication adherence
  6. systems for ensuring review by experienced or specialist practitioners[21]
  7. hospital accreditation

[edit] See also

[edit] References

  1. ^ Institute of Medicine (2000). To Err Is Human: Building a Safer Health System (2000). The National Academies Press. Retrieved on 2006-06-20.
  2. ^ Charatan, Fred (2000). Clinton acts to reduce medical mistakes. BMJ Publishing Group. Retrieved on 2006-03-17.
  3. ^ Leape LL (1994). "Error in medicine". JAMA 272 (23): 1851-7. doi:10.1001/jama.272.23.1851. PMID 7503827. 
  4. ^ Timothy P. Hofer, MD (Nov 2000). "What Is an Error?". . Effective Clinical Practice (American College of Physicians)
  5. ^ Rodney A. Hayward, MD (July 25, 2001). "Estimating Hospital Deaths Due to Medical Errors: Preventability Is in the Eye of the Reviewer". . Journal of the American Medical Association 286:415-420
  6. ^ . "Health Grades Quality Study Patient Safety in American Hospitals 2004 (Study Limitations)". . Health Grades, Inc.
  7. ^ Helmreich, Robert (2000). On error management: lessons from aviation. BMJ Publishing Group. Retrieved on 2006-03-17.
  8. ^ Weingart, Saul; Ross Wilson, Robert Gibberd, Bernadette Harrison (2000). Epidemiology of medical error. BMJ Publishing Group. Retrieved on 2006-03-17.
  9. ^ Barger LK, Ayas NT, Cade BE, Cronin JW, Rosner B, et al. (2006) Impact of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures. PLoS Med 3(12): e487 doi:10.1371/journal.pmed.0030487 [1]
  10. ^ a b When Doctors Don't Sleep, Talk of the Nation, National Public Radio, 13 Dec 2006.
  11. ^ Gaba, David (2000). Anaesthesiology as a model for patient safety in health care. BMJ Publishing Group. Retrieved on 2006-03-17.
  12. ^ Pease E. Minimum standards for a hospital pharmacy. Bull Am Coll Surg 1936;21:34-35
  13. ^ Chapter IV.1 Medication Distribution Systems, Garrison TJ (au) in Handbook of Institutional Pharmacy Practice, Smith MC and Brown TR eds, Williams and Wilkins Co. 1979,
  14. ^ Chapter IV.3 Developing Intravenous Admixture Systems, Woodward WA and Schwartau N (au) in Handbook of Institutional Pharmacy Practice, Smith MC and Brown TR eds, Williams and Wilkins Co. 1979,
  15. ^ Chapter 53 The Patient Profile System, Powell MF (au) in Handbook of Institutional Pharmacy Practice, Smith MC and Brown TR eds, Williams and Wilkins Co. 1986,
  16. ^ Chapter 31 Communicating Drug Information, Evens RP (au) in Handbook of Institutional Pharmacy Practice, Smith MC and Brown TR eds, Williams and Wilkins Co. 1986,
  17. ^ Kelly, Karen (2005). Study explores how physicians communicate mistakes. University of Toronto. Retrieved on 2006-03-17.
  18. ^ a b Dissociative Identity Disorder, doctor's reference. Merck.com (2005-11-01). Retrieved on 2008-03-30.
  19. ^ Bowden, C.L. (2001). "Strategies to Reduce Misdiagnosis of Bipolar Depression". Psychiatr Serv 52: 51-55. doi:10.1176/appi.ps.52.1.51. 
  20. ^ "Schizophrenia Symptoms", schizophrenia.com. Retrieved on 2008-03-30. 
  21. ^ Espinosa, James; Thomas Nolan (2000). Reducing errors made by emergency physicians in interpreting radiographs: longitudinal study. BMJ Publishing Group. Retrieved on 2006-03-17.

[edit] Books

  • Gawande, Atul. Complications: A Surgeon's Notes on an Imperfect Science. New York, NY: Metropolitan Books; 2002.
  • Wachter, Robert and Shojania, Kaveh. Internal Bleeding: The Truth Behind America's Terrifying Edidemic of Medical Mistakes. New York, NY: Rugged Land; 2004.
  • Banja, John Medical Errors and Medical Narcissism, 2005
  • Porter, Michael E. and Olmsted Teisberg, Elizabeth Redefining Health Care: Creating Value-Based Competition on Results, 2006

[edit] External links