___________________________________________ Medical Errors and the United States Healthcare System
4. Surgical Complications: Wrong side surgery/wrong patient surgeries are considered sentinel events by the NQF to describe a significant adverse medical error that should never take place. In Pennsylvania, during the period of 2015-2019, there was an average of 1.42 wrong-site surgeries reported each week or 368 wrong side surgery events during a period of 260 weeks [11]. Four of the most common errors in spinal surgery include operating on the wrong patient, doing the wrong procedure performing wrong level surgery, and/or performing wrong side surgery [12]. A retained surgical sharp (RSS) is a never event and defined as a lost sharp (needle, blade, instrument, guide wire, metal fragment) that is not recovered prior to the patient leaving the operating room. A “near-miss” sharp (NMS) is an intraoperative event where there is a lost surgical sharp that is recovered prior to the patient leaving the operating room. A recent, large-scale national survey-based study estimated the incidence of these events [13]. Most of each respondent group reported 1–5 lost sharp events over the last year: 91.7% of surgeons; 75.5% of anesthesiologists; 80.5% of nurses/ technologists. Unlike previous estimates that lost sharp objects are rare events, data from this survey suggest a higher incidence of 2.7 events per 10,000 surgeries or approximately 1 event per every 3800 surgeries. Surgical site infection, which is defined by the CDC as infection related to an operative procedure that occurs at or near the surgical incision within 30 days of the procedure, or within 90 days if prosthetic material is implanted at surgery, is among the most common preventable complication after surgery. Surgical site infections occur in 2% to 4% of all patients undergoing inpatient surgical procedures. Although most infections are treatable with antibiotics, they remain a significant cause of morbidity and mortality after surgery. They are the leading cause of readmissions to the hospital following surgery, and approximately 3% of patients who contract an infection will die as a consequence. Although infections are less common following ambulatory surgery than after inpatient procedures, they are also a frequent source of morbidity [14]. 5. Urologic-Related Issues: Urologic conditions that are misdiagnosed range from urinary tract infection (UTI) and asymptomatic bacteremia,[15] , [16] to interstitial cystitis/bladder pain syndrome,[17] to stress urinary incontinence,[18] to spontaneous rupture of the urinary bladder [19]. A study[15] of women who presented to an urban academic emergency department with genitourinary symptoms or diagnosed genitourinary infection found that 57% were treated for a UTI, without performing a urine culture. In addition, 14 of 22 women who were later found to have a sexually transmitted disease were misdiagnosed with a UTI. Although UTIs are common in hospitalized patients, many patients with asymptomatic bacteremia are misdiagnosed with UTI. In one study, approximately 30% of patients received antimicrobials within 48 hours prior to urine culture [16]. Some cases of misdiagnosis have severe consequences as is the case of spontaneous rupture of the urinary bladder, which is a rare and often life-threatening.
• Pharmacy errors: Pharmacy errors can involve such issues as the preparation or processing of a prescription or giving incorrect directions to patients. Researchers at a tertiary care medical center in Houston, Texas, recently monitored 1,887,751 medication orders, 92 medication error events, and 50 pharmacists. They determined that the overall error rate was 4.87 errors per 100,000 verified orders. Pharmacy errors were associated with workload, work environment, and number of pharmacists per shift. Factors such as the type of pharmacy degree, age, experience, and the number of years at an institution may also influence the error rate [24].
• Laboratory errors: Errors made in the laboratory can be technical, procedural, or the result of poor communication. The ECRI Institute evaluated 2,420 mistakes that occurred between 2011 and mid-2013. Only 4% of reported potentially harmful errors occurred in the laboratory itself. Nearly 75% of mistakes occurred in the pre-analytic stage, defined as the time frame in which tests are selected and ordered, specimens are identified and transported, and patients are prepared. Such mistakes were more likely to be linked to labels that had the wrong patient’s name, the wrong specimen ordered, and incomplete or missing information. The other 22% occurred in the post-analytic stage, when results were interpreted, reported, or stored [25].
WORKS CITED FOR “THE 5 MOST MISDAIGONSED CONDITIONS” https://qr2.mobi/5-misdiagnosed-cond
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