Medical Errors and the United States Healthcare System _ ___________________________________________
Site Marking. The marking of the surgical site is a preopera- tive procedure that allows the surgeon to mark the surgical site after a verbal confirmation with the patient or patient representative, and the attending nurse. The site mark acts as a visual confirmation to not only the surgeon, but the entire surgical team. Timeout and Intraoperative Verification. The timeout is the final pause prior to initiating a surgical procedure and should include all staff participating in the procedure. Intraoperatively, a verification process should be utilized to ensure accuracy (site and side) for the consented procedure. PARTNERSHIP FOR PATIENTS CORE SAFETY MEASURES Studies show the potential risk of some errors is far greater than others, with some likely to happen repeatedly. A Partnership for Patients study described the most common medical errors in the United States. Nine core patient safety areas of focus were identified:[32] Adverse Drug Events (Medication Errors); Catheter Associated Urinary Tract Infections (CAUTIs); Cen- tral Line-Associated Bloodstream Infections; Injuries from Falls and Immobility; Obstetrical Adverse Effects; Pressure Ulcers; Surgical Site Infections; Venous Thromboembolism; Ventilator-Associated Events. The following are strategies might be used to enhance safety and decrease the occurrence of some of these core safety issues. Adverse Drug Events/Medication Errors: A medication error is an error, of commission or omission, at any step along the pathway that begins when a clinician prescribes a medica- tion and ends when the patient actually receives the medica- tion. An adverse drug event is defined as harm experienced by a patient as a result of exposure to a medication. The occurrence of an adverse drug event does not necessarily indicate an error or poor-quality care. It is estimated that approximately 50% of adverse drug events are preventable [33]. In some cases, an adverse drug event is an unseen consequence of a medication reaction with therapeutic intent.
The authors noted that identifying the most severe ED adverse events and their preceding causes permits the development of action plans aligned to address root causes and the prioritiza- tion of action plan implementation [29].
ADDRESSING ROOT CAUSES: STRATEGIES FOR REDUCING COMMON MEDICAL ERRORS Human error is inevitable. Although we cannot eliminate human error, we can better measure the problem to design safer systems mitigating its frequency, visibility , and consequences. Strategies to reduce death from medical care should include three steps: 1. Making errors more visible when they occur so their effects can be intercepted. 2. Having remedies at hand to rescue patients. 3. Making errors less frequent by following principles that take human limitations into account (Figure 3) . The identification of errors needs to become more transparent. There needs to be standardized data collection and evaluation of the root cause of each error. Punishment is not helpful as it leads to the nondisclosure of errors or risk of error. Both individuals and hospital systems have unique responsibilities in the reduction of medical errors [30]. WRONG-SITE SURGERY Three primary strategies have been identified to reduce the likelihood of wrong-site surgery [31]. Preoperative Verification and Reconciliation. The veri- fication and reconciliation process is typically initiated by the admitting nurse in the preoperative area, but ultimately includes all staff members. The process includes the verifica- tion of the procedure to be performed with the patient or patient representative and allows for review of all relevant documents. Any discrepancies are immediately resolved with the attending surgeon. Medical Errors _V2 March 31, 2020
ADDRESSING ROOT CAUSES: STRATEGIES FOR REDUCING COMMON MEDICAL ERRORS Human error is inevitable. Although we cannot eliminate human error, we can better measure the problem to design safer systems mitigating its frequency, visibility, and consequences. Strategies to reduce death from medical care should include three steps: 1. Making errors more visible when they occur so their effects can be intercepted. 2. Having remedies at hand to rescue patients. 3. Making errors less frequent by following principles that take human limitations into account. 28
INDIVIDUAL AND SYSTEM RESPONSIBILITIES
MDFL0627 The identification of errors needs to become more transparent. There needs to be standardized data collection and evaluation of the root cause of each error. Punishment is not helpful as it leads to the nondisclosure of errors or risk of error. Both individuals Source: [30] Figure 3
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