Medical errors

The term "medical error" encompasses a diverse group of events that vary in magnitude
and potential to harm the patient. Medical errors are preventable adverse events.

A medical error has been defined as "an unintended injury caused by medical
management" that results in "measurable disability."

• Outcome dependant: Patients experiencing adverse outcomes or injury as a

consequence of medical care.
• Process dependant: This definition would incorporate errors that do not result in
injury (the so-called "near misses" or "close calls") and allow the implementation of
preventive strategies that will be more effective in decreasing medical error rates.

Defining medical error as an act of "omission or commission in planning or execution that

contributes or could contribute to an unintended result". It encompasses all measurable
adverse outcomes and "close calls" that can result from errors in planning and execution
of healthcare as well as errors of commission.

The IOM identifies an adverse event as an injury caused by medical management rather
than the underlying condition of the patient. If the adverse event can be attributed to an
error, it is classified by the IOM as a "preventable adverse event." A subset of these
preventable adverse events is called "negligent adverse events," where the care provided
fails to meet the standard of care and results in an adverse event.

Medical errors are associated with high morbidity and mortality and a high economic
burden.

Preventable adverse events in the United States of America (US) cause an estimated
44,000 to 98,000 deaths in hospitals each year. Cost about $50 billion / year.

Therefore, identifying system processes that lead to medical errors and implementing
corrective measures is the primary goal in treating this problem.
Medical Errors
Types of Medical Errors

1. Medication error:
• wrong drug or dose,
• via the wrong route,
• at an incorrect time, or
• to the wrong patient.

The reported incidence of medication error-associated adverse events in acute

hospitals is around 6.5 per 100 admissions.

2. Diagnostic errors: Defined as "missed opportunities to make a correct or timely

diagnosis based on the available evidence, regardless of patient harm."
3. In hospitalized patients, wound infections, pressure ulcers, falls, healthcare-
associated infections, and technical complications constitute another group of
preventable medical errors.
4. The most common systems-error is failure to disseminate drug knowledge and
patient information. This, in essence, is a communication failure, whether with the
patient or other providers.
5. Failure to employ indicated tests is another medical error that can lead to
diagnostic delays or errors.
6. Using outdated tests or treatments or failing to respond to the results of tests or
monitoring also constitutes a type of medical error.
7. Treatment errors include errors during the performance of a test or procedure
and inappropriate treatment.
Medical Errors vs. Negligence
Intent

Medical error: Usually unintentional and without malicious intent

Medical negligence: Involves a failure to act competently and responsibly

Standard of care

Medical error: Whether the act or omission violates the recognized standard of care

Medical negligence: Whether the medical professional breached their duty of care

Examples

Medical error: A surgeon accidentally nicks a blood vessel during a routine procedure

Medical negligence: A surgeon performs a surgery without running necessary tests first

Compensation

Medical error: Compensation may cover medical costs, lost wages, and pain and suffering

Medical negligence: Compensation may cover medical costs, lost wages, pain and
suffering, and punitive damages
Risk Factors that Increase the Incidence of Medical Errors
• Schedule instability
• Sleep Deprivation
• Provider burnout
• Workload and nurse-to-patient ratio (Staff shortages)
• Poor communication
• Incorrect use of medications
• Employee hesitation to ask for help
• Lack of patient information
• Poor environmental conditions

In any healthcare process, some error is inevitable. As indicated in the US Institute of

Medicine's report To Err is Human, the challenge is to cut the rate of error to a minimum.

• To safeguard public trust in the medical profession, and

• the responsibility to disclose medical errors is acknowledged in codes of
professional ethics
• patients have a right to information about errors in terms of the respect due to
them as persons, and indeed patients expect doctors to recognize this duty.
• failure to disclose an error during the course of patient care may compromise not
only autonomy but also informed consent. eg treatment of injury.
Disclosure of Medical errors
Duty of disclosure: On doctors or establishments.

Doctors and others, though possibly willing to accept responsibility and express regret,
may be reluctant to pursue this course if it amounts to admission of guilt or legal liability.

Two types of apologies— 'apology of sympathy' and 'apology of responsibility'.

Some legal jurisdictions consider an apology as evidence of liability. Thus, the risks and
benefits of an apology should be weighed up beforehand by the doctors and hospital
administrators; This discourages a timely apology for fear of encouraging a lawsuit.

In some states, apologies or expressions of regret to patients are legally protected.

An appropriately worded apology by the doctor can reduce the likelihood of a lawsuit.

Disclosure

In most cases, it is the physician who faces the responsibility of disclosing mistakes to
patients and their families.

Mistake disclosure management plan (MDMP): MDMP is a two-step process.

1. physician preparation:
Involves focusing on issues that physicians personally need to address before
revealing the mistake to patients so that the needs of both physician and patient
are met. This step helps physicians intellectualize and emotionally cope with the
fact that a mistake has occurred “under their watch.”
2. mistake disclosure strategies:
Formulating and adhering to a method of disclosing mistake messages that is
geared toward preserving the integrity of the physician-patient relationship.
Components of the Mistake Disclosure Management Plan

Step Primary Components Issues addressed

beneficiary
• Overcoming
1. Physician Physicians Task 1:
shame
preparation for Recognizing and
• Overcoming
mistake disclosure talking about
uncertainty
emotions
• Coping with
anxieties
• Coping with
threat of
liability

Task 2: Gathering preliminary

Initial information scope of problem
seeking
• Timing of
2. Formulating and Patient/family Task 1:
mistake
delivering mistake members, Context of
disclosure
disclosure physicians disclosure delivery
• Presence of
messages
other people at
disclosure

• Fostering trust
Task 2:
Message
Content of mistake
sequencing
disclosure messages
• Forecasting
and disclosure
Incremental
sequencing
disclosure
• Full apology
Disclosure without the physician preparation step is more likely to result in

• the physician asking for forgiveness from the patient (tending to be more about
the physician than the patient) instead of helping the patient come to terms with
the mistake event.
• the physician quickly discloses and departs before the patient can ask questions.

Steps of disclosure

• Begin by stating there has been an error;

• Describe the course of events, using nontechnical language;
• State the nature of the mistake, consequences, and corrective action;
• Express personal regret and apologize;
• Elicit questions or concerns and address them; and
• Plan the next step and next contact with the patient.

Points to consider

• Errors by others
• Follow words with actions
• Legal concerns: Reporting