3
3
Preventing Errors for Healthcare Professionals: Summary
HISTORY OF MEDICAL ERROR ISSUES The systematic study of medical errors dates back to 1954, beginning with research on anesthesia-related deaths . A significant milestone was the 1962 report revealing 16 errors per 100 medication doses in hospitals, which sparked ongoing research initiatives. The 1970s and 1980s saw expanded research into various healthcare settings and improved monitoring systems. The issue gained major public attention in the 1990s, particularly with the economic impact of adverse drug events, estimated at $76 billion annually. The watershed moment came with the 1999 publication of "To Err Is Human," which revealed that 44,000-98,000 Americans died annually due to medical errors. This report, building on the work of physicians Lucian Leape and David Bates, catalyzed national efforts to improve patient safety and remains a pivotal moment in healthcare quality improvement. Contributing Causes of Medical Errors Medical errors stem from eight primary categories of contributing factors: 1. Communication Factors : Miscommunication is the most common cause of errors, affecting both healthcare team interactions and patient-provider communication. 2. Inadequate Information Flow : Poor information transfer during patient transitions and fragmented healthcare systems can lead to lost or incomplete medical information, while health information technology can both help and potentially create new risks. 3. Human Factors : Issues like fatigue, illness,
LEARNING TIP! 4. Patient-Related Factors: These include improper patient identification, incomplete assessments, and inadequate
patient education. Currently, the Joint Commission lists Goal 1 as “to identify patients correctly.” Proper patient identification using at least two identifiers is crucial. 5. Organizational Transfer of Knowledge : Deficiencies in staff orientation and education, particularly affecting new, temporary, or floating staff members. 6. Workforce Issues : Inadequate staffing 7. Technology Failures : While technology can prevent errors, equipment failures and inadequate training on medical devices can lead to serious injuries. levels and supervision can lead to increased error rates and compromised patient care. 8. Inadequate Policies and Procedures : The lack of standardized, updated policies and procedures can lead to inconsistent care and medical errors. Identifying and Analyzing Medical Errors The accurate measurement of medical errors presents significant challenges, primarily because most data relies on self-reporting systems, which typically capture only a small fraction of actual incidents. Healthcare professionals must first recognize an error, understand that it is reportable, and feel safe reporting it without fear of consequences. To improve error detection, two major tools have been developed: 1. AHRQ's Patient Safety Indicators (PSIs) : ○ Includes 20 hospital-level and 7 area-level indicators ○ Used with hospital discharge data to screen for potential errors
and drug use can impair healthcare providers' ability to follow protocols and best practices.
Powered by FlippingBook