Medical Error and Harm: Understanding, Prevention, and Control
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A follow-up to the IOM study found that medication errors are among the most common medical mistakes, harming at least 1. According to the study, , preventable drug-related injuries occur each year in hospitals, , in long-term care settings, and roughly , among Medicare recipients in outpatient clinics. The report stated that these are likely to be conservative estimates.
None of these figures take into account lost wages and productivity or other costs. According to a Agency for Healthcare Research and Quality report, about 7, people were estimated to die each year from medication errors — about 16 percent more deaths than the number attributable to work-related injuries 6, deaths. One extrapolation suggests that , people die each year partly as a result of iatrogenic injury.
The World Health Organization registered 14 million new cases and 8. As the number of cancer patients receiving treatment increases, hospitals around the world are seeking ways to improve patient safety, to emphasize traceability and raise efficiency in their cancer treatment processes. A study released in found medical error is the third leading cause of death in the United States, after heart disease and cancer.
Researchers looked at studies that analyzed the medical death rate data from to and extrapolated that over , deaths per year had stemmed from a medical error, which translates to 9. However, the mistake would be recorded in the third type of study. If a doctor recommends an unnecessary treatment or test, it may not show in any of these types of studies.
Medical errors are associated with inexperienced physicians and nurses, new procedures, extremes of age, and complex or urgent care. Falls, for example, may result from patients' own misjudgements. Human error has been implicated in nearly 80 percent of adverse events that occur in complex healthcare systems. The vast majority of medical errors result from faulty systems and poorly designed processes versus poor practices or incompetent practitioners. Complicated technologies,   powerful drugs, intensive care, and prolonged hospital stay can contribute to medical errors.
In , The Institute of Medicine released " To Err is Human ," which asserted that the problem in medical errors is not bad people in health care—it is that good people are working in bad systems that need to be made safer. Poor communication and unclear lines of authority of physicians, nurses, and other care providers are also contributing factors. Other factors include the impression that action is being taken by other groups within the institution, reliance on automated systems to prevent error. The American Institute of Architects has identified concerns for the safe design and construction of health care facilities.
As a result, diagnostic procedures or treatments cannot be performed, leading to substandard treatment. The Joint Commission 's Annual Report on Quality and Safety found that inadequate communication between healthcare providers, or between providers and the patient and family members, was the root cause of over half the serious adverse events in accredited hospitals.
Cognitive errors commonly encountered in medicine were initially identified by psychologists Amos Tversky and Daniel Kahneman in the early s. Jerome Groopman , author of How Doctors Think , says these are "cognitive pitfalls", biases which cloud our logic. For example, a practitioner may overvalue the first data encountered, skewing his thinking. Another example may be where the practitioner recalls a recent or dramatic case that quickly comes to mind, coloring the practitioner's judgement. Another pitfall is where stereotypes may prejudice thinking.
In this framework, many cognitive errors reflect over-reliance on System 1 processing, although cognitive errors may also sometimes involve System 2. Sleep deprivation has also been cited as a contributing factor in medical errors. Practitioner risk factors include fatigue,    depression, and burnout. Errors in interpreting medical images are often perceptual instead of "fact-based"; these errors are often caused by failures of attention or vision.
Errors can include misdiagnosis or delayed diagnosis, administration of the wrong drug to the wrong patient or in the wrong way, giving multiple drugs that interact negatively, surgery on an incorrect site, failure to remove all surgical instruments , failure to take the correct blood type into account, or incorrect record-keeping. A 10th type of error is ones which are not watched for by researchers, such as RNs failing to program an IV pump to give a full dose of IV antibiotics or other medication.
According to a study from Johns Hopkins Medicine, medical errors are the third-leading cause of death in the United States. A large study reported several cases where patients were wrongly told that they were HIV-negative when the physicians erroneously ordered and interpreted HTLV a closely related virus testing rather than HIV testing.
Female sexual desire sometimes used to be diagnosed as female hysteria. Sensitivities to foods and food allergies risk being misdiagnosed as the anxiety disorder Orthorexia.
Medical Error Prevention
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. The misdiagnosis of schizophrenia is also a common problem. There may be long delays of patients getting a correct diagnosis of this disorder. Delayed sleep phase disorder is often confused with: psychophysiological insomnia; depression ; psychiatric disorders such as schizophrenia , ADHD or ADD ; other sleep disorders; or school refusal.
Practitioners of sleep medicine point out the dismally low rate of accurate diagnosis of the disorder, and have often asked for better physician education on sleep disorders. Cluster headaches are often misdiagnosed, mismanaged, or undiagnosed for many years; they may be confused with migraine, "cluster-like" headache or mimics , CH subtypes, other TACs trigeminal autonomic cephalalgias , or other types of primary or secondary headache syndrome.
Asperger and Autism tend to get undiagnosed or delayed recognition and delayed diagnosis   or misdiagnosed. The DSM-5 field trials included "test-retest reliability" which involved different clinicians doing independent evaluations of the same patient—a new approach to the study of diagnostic reliability. Misdiagnosis is the leading cause of medical error in outpatient facilities. Mistakes can have a strongly negative emotional impact on the doctors who commit them. Some physicians recognize that adverse outcomes from errors usually do not happen because of an isolated error and actually reflect system problems.
Therefore, even if a doctor or nurse makes a small error e. There may be several breakdowns in processes to allow one adverse outcome. Essayists imply that the potential to make mistakes is part of what makes being a physician rewarding and without this potential the rewards of medical practice would be diminished. Laurence states that "Everybody dies, you and all of your patients. All relationships end. Would you want it any other way?
Medical Error and Harm: Understanding, Prevention, and Control
On a daily basis, it is both a privilege and a joy to have the trust of patients and their families and the camaraderie of peers. There is no challenge to make your blood race like that of a difficult case, no mind game as rigorous as the challenging differential diagnosis, and though the stakes are high, so are the rewards. Forgiveness , which is part of many cultural traditions, may be important in coping with medical mistakes. Inability to forgive oneself may create a cycle of distress and increased likelihood of a future error.
However, Wu et al.
The Anatomy of Medication Errors
Gallagher et al. A study by Wendy Levinson of the University of Toronto showed surgeons discussing medical errors used the word "error" or "mistake" in only 57 percent of disclosure conversations and offered a verbal apology only 47 percent of the time. Patient disclosure is important in the medical error process. The current standard of practice at many hospitals is to disclose errors to patients when they occur. In the past, it was a common fear that disclosure to the patient would incite a malpractice lawsuit. Many physicians would not explain that an error had taken place, causing a lack of trust toward the healthcare community.
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In , 34 states passed legislation that precludes any information from a physician's apology for a medical error from being used in malpractice court even a full admission of fault. However, "there appears to be a gap between physicians' attitudes and practices regarding error disclosure. Willingness to disclose errors was associated with higher training level and a variety of patient-centered attitudes, and it was not lessened by previous exposure to malpractice litigation".
Consequently, in the United States , many states have enacted laws excluding expressions of sympathy after accidents as proof of liability. However, "excluding from admissibility in court proceedings apologetic expressions of sympathy but not fault-admitting apologies after accidents" . Disclosure may actually reduce malpractice payments. In a study of physicians who reported having made a mistake, it was offered that disclosing to non-physician sources of support may reduce stress more than disclosing to physician colleagues.
It is possible that greater benefit occurs when spouses are physicians.
Discussing mistakes with other physicians is beneficial. Disclosure of errors, especially 'near misses' may be able to reduce subsequent errors in institutions that are capable of reviewing near misses.
Based on anecdotal and survey evidence, Banja  states that rationalization making excuses is very common among the medical profession to cover up medical errors. A survey of more than 10, physicians in the United States came to the results that, on the question "Are there times when it's acceptable to cover up or avoid revealing a mistake if that mistake would not cause harm to the patient?
On the question "Are there times when it is acceptable to cover up or avoid revealing a mistake if that mistake would potentially or likely harm the patient? 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. Minor to moderate consequences from medication errors are also less likely to be detected and therefore not monitored or documented [ ].
Thus, unless the panel assessing harm accounts for whether the medication error was detected, assessment of actual harm will be biased towards non-minor harms. Finally, assessing actual harm requires information on the individual patient and the treatment received to be documented, and the poor quality of this information is frequently described to be a significant limitation [ 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , ].