BACKGROUND AND SCOPE
at approximately $20 billion each year (Rodziewicz et al., 2023).
The landmark report of 2000, To Err Is Human: Building a Safer Health System , from the Institute of Medicine (IOM), now known as the Health and Medicine Division of the National Academies of Sciences, Engineering and Medicine, highlighted the broad reach of medical errors in the United States. That report identified that medical errors result in harm to 1 in every 25 hospitalized patients. In 2000, Kohn et al. reported an estimated 44,000 to 98,000 preventable deaths are attributable to medical errors. Since that landmark report, the number of Americans whose deaths are attributable to preventable harm has also been estimated between 210,000 and 440,000 deaths per year, or one sixth of all deaths (James, 2013). Watson (2016) equated the number of hospitalized patient deaths to the downing of approximately 10 jumbo airliners weekly, with the loss of all passengers on board the planes. The Agency for Healthcare Research and Quality (AHRQ, 2014) identified that 1 of every 10 patients developed a hospital-acquired infection (HAI) or had a fall, a pressure ulcer, or a medication error during their hospital stay. Nanji et al. (2016) found that 1 out of every 2 surgeries, or 50% of surgical patients, had an adverse drug event and/or a medication error. According to Singh et al. (2014), more than 12 million outpatients are recipients of a diagnostic error, and more than half of those diagnostic errors to patients were possibly harmful. Among Medicare recipients, approximately one third of patients in skilled nursing facilities received harm in the form of an adverse event, with greater than half of the events deemed preventable (U.S. Department of Health and Human Services, Office of the Inspector General, 2014). Bates et al. (2023) recently published that now nearly 25% of people who are hospitalized experience harm by the care they receive and approximately one-fourth of these events were preventable. As a culminating result, the financial impact of medical errors on the healthcare system at large is estimated
Evidence-Based Practice Alert! The COVID-19 Global Pandemic & HAI Incidence Throughout 2020-2021, the United States and around the globe had unparalleled challenges due to the COVID-19 pandemic, which impacted surveillance for and incidence of hospital acquired infections (HAIs). “Compared to pre-pandemic years, hospitals across the nation experienced higher than usual hospitalizations and shortages in healthcare personnel and equipment, which may have resulted in deterioration in multiple patient safety metrics since the beginning of the pandemic” (Center for Disease Control and Prevention [CDC], 2022, n.p.). Since the release of the IOM report, ARHQ (2014) suggested a 17% decrease in the number of hospital- acquired conditions and the number of preventable deaths of hospitalized patients. However, “the number of preventable inpatient deaths in the USA is commonly estimated as between 44,000 and 98,000 deaths annually” (Rodwin et al., 2020, p. 2099) and the CDC (2022) recently reported that one in 31 patients in the United States, and 1 in 43 nursing home residents contracted at least one HAI. Healthcare professionals at the “sharp end,” or closest to the patient, along with leaders in every capacity and setting, have a moral and ethical obligation to design and implement systems and processes to mitigate medical errors, thus improving the safety of patients.
TERMS USED TO DESCRIBE MEDICAL ERRORS AND PATIENT SAFETY
condition) that reaches a patient and results in any of the following: ○ Death. ○ Permanent harm. ○ Severe temporary harm and intervention required to sustain life. (TJC, 2023b) ● Error : The term error can be further described in several ways: ○ Error of commission : An error of commission is the occurrence of harm to a patient due to a wrong act, or due to a right act that was not performed correctly (Rodziewicz et al., 2023). ○ Error of omission : This refers to failing to act or failing to perform a specific treatment that was determined for a patient (Rodziewicz et al., 2023). ○ Active Errors : Active errors occur at the level nearest the patient by a healthcare provider, and their effects are felt immediately (Rodziewicz et al., 2023), for instance, a surgeon performing a total knee arthroplasty on the wrong lower extremity. ○ Latent errors : These are organization or design errors that are beyond the control of the individual. Examples of latent errors include errors in system design, faulty maintenance of equipment, and ineffective organizational management. The effect of a latent error may not appear for months or years but can lead to many active errors, resulting in severe consequences (Rodziewicz et al., 2023).
The field of patient safety utilizes several terms to describe medical errors and the associated safety issues. Many of the terms overlap and can be confusing to the members of the healthcare team. Key definitions are described here and will be expanded upon throughout the course. ● Adverse event (AE) : Often used interchangeably with harm . The classic definition developed by scholars from the Institute for Healthcare Improvement (IHI) defines adverse event , or harm , as “unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalization, or that results in death” (Griffin & Resar, 2009, p. 5). In other words, an adverse event is a type of injury that is due to an error in medical or surgical treatment, not the underlying medical condition (Rodziewicz et al., 2023). ● Adverse drug event (ADE) : An adverse drug event is injury to a patient attributable to medical care that involves the use of medications (Rodziewicz et al., 2023). ● Near miss or close call : A near miss or a close call is a potential adverse event or an error that could have caused harm but did not, either by chance or by someone or something intervening to prevent the error (Rodziewicz et al., 2023). ● Sentinel event : A sentinel event is an occurrence that signals the need for immediate investigation and response by the healthcare team (Rodziewicz et al., 2023). The Joint Commission (TJC) defines a sentinel event as “a patient safety event" (not primarily related to the natural course of the patient’s illness or underlying
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