___________________________________________ Medical Errors and the United States Healthcare System
‒ The analysis progresses from special causes in clinical processes to common causes in organizational processes and systems and identifies potential improvements in these processes or systems. ‒ The goal is to decrease the likelihood of such events in the future by implementing strategies to prevent the event from occurring again. CATEGORIES OF MEDICAL ERRORS Many preventable adverse events can be associated with more than one type of medical error. Although there are many different ways to categorize medical error, and categories may overlap, the following classifications are common. • Misdiagnosis/Diagnostic errors: Diagnosis errors are errors that occur when a diagnosis is missed, wrong, or delayed [15]. Preventing medical misdiagnosis is a recognized national public health priority [16]. In their landmark 2015 report Improving Diagnosis in Healthcare, the National Academy of Medicine (NAM) stated that “most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences”[17]. Diagnostic error rates in real- world practice are not known, but a commonly cited estimate is that 10–15% of all diagnoses are incorrect [16]. A 2021 review article found that missed vascular events, infections, and cancers account for 75% of serious harms from diagnostic errors and 15 diseases account for nearly half of all serious misdiagnoses [16]. • Systems or process errors: Systems or process errors involve predictable human failings in the context of poorly designed systems [18]. • Active errors: Active errors nearly always involve frontline staff members and occur at the point of contact between a human and some part of a larger system [18]. • Latent errors: Sometimes referred to as “accidents waiting to happen,” latent errors involve failures of organization or design (e.g., systems and processes) that allow active errors to cause harm [18]. • Medication errors: Medication errors are “any
TERMINOLOGY
Medical error is defined as harm to a patient that results from either [12] [13]. • The failure of a planned action to be completed as intended or • The use of a wrong plan to achieve an objective. • Medical error can be associated with failures in medical practice, products, procedures, and/or systems. Medical error requires two critical parts: harm and whether the harm or error could have been prevented [12]. • Other terms related to medical error include.12-14 • Safety: Freedom from accidental injury. • Adverse drug event: Injury resulting from the use of a drug caused by an adverse drug reaction, a medication error, or an overdose. An adverse drug event frequently necessitates discontinuation of the drug and potentially administering an antagonist. • Adverse drug reaction: Unavoidable, appreciably noxious, or unpleasant reaction that occurs during the normal, proper use of a medical product. Some drug reactions may be minor and temporary; others have the potential to be permanent and serious. • Medication errors: Errors that occurs due to mistakes made in the processes of the drug’s prescribing, transcribing, dispensing, administering, or monitoring. • Near-miss: Error that is detected and corrected before harm can be done. • Sentinel event: Unexpected occurrence involving death or serious physical or psychological injury, or the risk of death or such an injury. A sentinel event indicates the need for immediate investigation and response. The terms “sentinel event” and “error” are not synonymous; not all sentinel events occur because of an error, and not all errors result in sentinel events. • Root Cause Analysis: Root cause analysis is a process for identifying factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event. ‒ A root cause analysis focuses primarily on systems and processes, not on individual performance.
preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer.”[19] The FDA receives approximately 100,000 reports each year associated with suspected medication error. These reports come from drug
29
MDFL0627
Powered by FlippingBook