DEFINING MEDICAL ERRORS
exacted by safety problems has remained high (Classen et al., 2011; James, 2013; Landrigan et al., 2010; Makary & Daniel, 2016). Harms caused during care carry significant mortality, morbidity, and quality-of life implications, no less than obesity, airplane or motor vehicle crashes, and breast cancer. Despite increased focus and some indications of improvement, about 1 in 10 patients develop an adverse event, such as a healthcare-acquired infection, pressure ulcer, preventable adverse drug event, or a fall, during hospitalization (AHRQ, 2014; Bates et al. 2023). The World Health Organization (WHO, 2023) has reported that 1 in 10 patients who are hospitalized experience some type of harm due to care provided, and greater than 50% of these cases are preventable. Ten percent of surgical procedures performed each year globally have an occurrence of harm (WHO, 2023). About 50% of errors in healthcare are due to medications (WHO, 2023). Between 5% and 20% of doctor- patient encounters experience a diagnostic error (WHO, 2023). Globally, there are 421 million hospitalizations and approximately 42.7 million adverse events each year (WHO, 2019).
In the Institute of Medicine (IOM) 1999 report To Err Is Human: Building a Safer Healthcare System , an error is defined as the failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning). A medical error can also be an inaccurate or incomplete diagnosis of a disease, injury, syndrome, behavior, infection, or other ailment. Medical errors can result in injury or death from mistakes made by people or by gaps in system processes that place patients at risk. The failure of a patient to respond to treatment or the physical differences among patients in regard to side effects of certain treatments can affect the degree of success from any particular treatment, but it is not a medical error. In 2015, the National Patient Safety Foundation (NPSF) convened a panel of experts to discuss the current state of patient safety. The publication, Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human identifies that despite progress in the past nearly 20 years, patient safety remains an important public health issue. Preventable harm remains unacceptably frequent—in all settings of care and among all patient populations. Studies suggest that the overall toll
HISTORY OF MEDICAL ERRORS ISSUE
of drug-related hospital admissions. In 1995, there was a startling economic estimate of adverse drug events set at about $76 billion annually (Kohn et al., 2000). Medical errors are not a new concern. However, this topic gained attention in the 1990s when government sponsored research about the problem was undertaken by physicians Lucian Leape and David Bates. The 1999 release of To Err Is Human and its subsequent publication in book form has been credited with galvanizing national action to improve patient safety (Kohn et al., 2000). Research related to patient safety has been part of healthcare literature for more than four decades. The Agency for Healthcare Research and Quality (AHRQ) funded a series of research studies examining the frequency and causes of medical errors. Based on these studies, the Institute of Medicine (IOM) estimated that as many as 44,000 to 98,000 Americans die in hospitals each year as a result of medical errors (Kohn et al., 2000). In light of these studies, healthcare leaders have rallied to shrink that alarming figure.
One of the earliest studies of a medical error was a 1954 analysis of causes of death during anesthesia administration (Beecher & Todd, 1954). Early studies indicated that medication errors accounted for a significant proportion of adverse patient care events. Influential research relating to medication errors includes a report in 1962 which demonstrated a rate in hospitals of 16 errors/100 doses of medication (Barker & McConnell,1962). Because of this report, there have been ongoing initiatives to investigate medication errors and the commencement of setting forth important principles for the conduct of the research of medication errors. By the 1970s, medication error research extended into non-acute-care settings such as nursing homes, outpatient pharmacies, and special patient environments. Early work in the 1970s and 1980s included more effective monitoring of dispensing systems to reduce error. Commentaries were written on the exact nature of medication errors sparking increased public policy attention into the late 1980s. Interest in patient safety and medication errors continued to grow in the 1990s. In addition to evaluating occurrences of medical errors, a work was published regarding a meta-analysis
CONTRIBUTING CAUSES OF MEDICAL ERRORS
Multiple factors are attributed to medical errors, and the contributing causes can be grouped into eight categories (AHRQ, 2003). This section summarizes these factors. Communication factors Miscommunication represents the most common cause of errors impacting the patient (Rodziewicz et al., 2023). Lack of clear oral and written communication among teams and between care providers and patients jeopardizes patient care. Miscommunication can occur across and within Inadequate information flow Inadequate information flow can affect the availability of critical information that is needed to influence patient care decisions. Patient transitions or movement across and within acute care settings, community settings, and the patients’ homes are times when patients are at increased risk of harm. For example, confusing and incomplete information
healthcare settings and among anyone involved in the care of patients. All members of the interprofessional team need to be knowledgeable about effective communication techniques that focus on patient safety (Interprofessional Education Collaborative, 2016). and/or decreased sharing of information about the patient throughout the care continuum could lead to adverse events (Finkelman, 2016). A decentralized and fragmented healthcare system can result in poorly documented or lost information on laboratory tests, diagnostic tests, or medical information, further contributing to medical errors. Investing
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