• An estimated 29% of Medicare patients in rehabilitation hospital stays experienced an adverse event and half of these were considered preventable, which is similar to findings regarding adverse events in hospitals and skilled nursing facilities (27% and 33%, respectively. 7 • An assessment of the frequency and types of errors identified by patients who read open ambulatory visit notes found 20% of patients who read a note reported finding a mistake and 40% perceived the mistake as serious. Among patient-reported very serious errors, the most common characterizations were mistakes in diagnoses, medical history, medications, physical examination, test results, notes on the wrong patient, and left vs right side. 8 Medical Error or Unintended Consequence? The term medical error captures all the unintended events that occur during a patient’s care cycle. These can be as innocent as the wrong doctor’s name placed into a chart, or a missed dose of medication that has no consequences to the patient. Some medical errors are discovered before any harm occurs, and some are so benign they go completely unnoticed. 9 Some clinicians believe that the term medical error is excessively negative, antagonistic, and perpetuates a culture of blame. Many experts suggest the term medical error should not be used at all, because, for example, an adverse medication event could be an unintended consequence of a therapeutic intervention. However, adverse patient outcomes may occur because of medical errors and to delete the term obscures the goal of preventing and managing its causes and effects. 10
Regardless of the nomenclature, medical errors typically occur from the convergence of multiple contributing factors. Public and legislative intolerance for medical errors typically illustrates a lack of understanding that some errors may not be preventable with current technology or the resources available to the practitioner. 11 The trend is for patient safety experts to focus on improving the safety of healthcare systems to reduce the probability of errors and mitigate their effects rather than focus on an individual’s actions. Medical errors represent an opportunity for constructive changes and improved education in healthcare delivery. 11 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. •
INTRODUCTION
Medical errors are an under-recognized cause of death in the United States. Error rates are significantly higher in the United States compared with other developed countries such as Canada, Australia, New Zealand, Germany, and the United Kingdom. 1 Patient safety experts at Johns Hopkins analyzed medical death rates over an 8-year period and estimated that >250,000 deaths each year are due to medical error in the United States (Figure 1). 2 This statistic makes medical errors the third highest cause of death in the United States, accounting for 10% of all deaths. 2 Unfortunately, the way that the Centers for Disease Control and Prevention collects national health statistics fails to classify medical errors separately on death certificates. Because medical errors are not listed, they do not get the public attention given to other leading causes of death such as cancer and heart disease. 2 Medical errors increase personal and institutional financial burdens, adding an estimated $20 billion to US healthcare costs annually. 3 Beyond the emotional toll on the patient, medical errors have substantial negative effects on the mental and emotional well-being of the providers who are involved. 4 These negative effects include guilt, shame, anxiety, fear, depression, posttraumatic stress disorder and suicidality. 4 Although improvement has occurred in specific areas, significant challenges remain. For example: • One in two surgeries involved a medication error and/or an adverse drug event. 5 • Approximately 5% of all adult Americans experience a diagnostic error in outpatient settings every year. 6
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.
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Medical Errors _V2 March 31, 2020
Figure 1. Death in the United States
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Medical errors increase personal and institutional financial burdens, adding an estimated $20 billion to US healthcare costs annually. 3 Beyond the emotional toll on the
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