7
7
Preventing Errors for Healthcare Professionals: Summary
PREVENTION OF MEDICAL ERRORS The prevention of medical errors requires a comprehensive systems approach rather than isolated interventions. The National Patient Safety Foundation (NPSF) outlined eight key recommendations for this approach: 1. Establish and maintain a safety culture through leadership 2. Implement centralized safety oversight 3. Develop meaningful safety metrics 4. Increase safety research funding 5. Address safety across all care settings 6. Support the healthcare workforce 7. Partner with patients and families 8. Ensure safe technology implementation Public concern about medical errors remains significant, with surveys showing: • 42% of Americans have been affected by medical errors personally or through someone they know • 61% worry about receiving wrong medications • 58% fear negative drug interactions • 56% are concerned about procedure complications • An estimated 1.5 million preventable injuries occur annually Regarding hospital accountability, research shows that hospitals currently bear only about 22% of injury-related costs, while externalizing 78%. This cost distribution provides limited financial incentive for hospitals to invest in safety improvements. Patient safety advocates are working to demonstrate that investments in safer practices can lead to reduced malpractice costs and other expenses, making a business case for safety improvements. TYPES OF MEDICAL ERRORS Medical errors can be categorized into several major types: 1. Diagnostic Errors : ○ Misdiagnosis of symptoms ○ Under-diagnosis of conditions
○ Failure to use indicated diagnostic tests ○ Misreading of test results ○ Failure to act on abnormal tests 2. Medication Errors : ○ Occurs across four stages: ordering, transcribing, dispensing, and administration ○ Causes at least one death daily and 1.5 million injuries annually ○ Includes adverse drug events (ADEs) and reactions and can result in a number of different physical consequences, raging from allergic reactions to death ○ Results from poor handwriting, confusion with similar drug names, poor packaging design, and dosing confusion 3. Treatment Errors : ○ Incorrect choice of therapy ○ Misdiagnosis leading to inappropriate treatment ○ Failure to prevent injury ○ Inadequate follow-up or monitoring 4. Surgical Errors : ○ Wrong-site surgery ○ Retained surgical instruments/failure to remove foreign object ○ Wrong-patient operative procedures ○ Anesthesia-related erro rs 5. Systems Errors : ○ Poor system design ○ Organizational factors ○ Healthcare professional fatigue (24-hour shifts) ○ Complex processes increasing error probability ○ Inadequate technology utilization The Institute of Medicine (IOM) notes that most errors stem from system design and organizational factors rather than individual negligence or lack of training . Prevention requires addressing both human and system factors while maintaining focus on patient safety.
Powered by FlippingBook