Medical errors in the United States cost an estimated 37.6 billion dollars annually in extra healthcare expenses, lost income and disability insurance. And to families, no amount of money can compensate the lost of a loved one to a preventable mistake. A 1999 study from the Institute of Medicine (IOM) reported that errors accounted for between 44,000 to 98,000 fatalities per year. It is the eighth leading cause of death and kills more people than motor vehicle crashes, breast cancer and AIDS.
Each year, millions of patients seek the expertise of healthcare professionals with the expectation that they will be well-taken care-of. Unfortunately, for 3 percent that are admitted to hospitals, their stay is complicated by minor errors that may delay discharge by a few hours, or major mistakes that results in a one-way ticket to the morgue.
A survey of patients reported that 42 percent had been affected by a medical error, either personally or through a friend or relative. 32 percent of the respondents indicated that the error had a permanent, negative effect on the patient's health.
What constitutes a medical error?
The IOM defines medical errors as the "failure to complete a planned action as intended or the use of a wrong plan to achieve an aim" that results in an injury not attributable to the illness, but is a complication of the treatment.
One example is a patient that suffers from an anaphylactic reaction to a medication who had no known drug allergies. Another example would be a nurse that dispenses the wrong medication to the wrong patient. We must be careful to distinguish between adverse events that cannot be prevented and those that can.
In the above example, there would be no way to know whether a patient would have an allergic reaction to a new medication. But if we were to administer a drug to an allergic patient, there would be no excuse. Medical treatments and surgical interventions are fraught with inherent risks and complications and to simply be afraid of committing an error would be a disservice to the profession.
However, identifying and preventing careless errors of neglect or insufficient knowledge would certainly save the lives of many patients and drastically reduce the costs associated with medical mistakes.
One landmark study reported that 70 percent of adverse events discovered in 1,133 medical records were preventable (). Another study reviewed 15,000 medical records in Colorado and Utah and found that 54 percent of surgical errors were preventable (). These percentages highlight again, the significant number of potential lives that can be improved or saved by implementing ways that we can reduce medical errors.
In this essay, I highlight that the increasing complexities of the medical healthcare system with overworked staff are factors that contribute to medical errors. As well, the lack of accountability in tracking errors at many centers often leads to the failure to learn from past mistakes, thereby dooming history to repeat itself. Yet, there is hope that with education, technology and better awareness we can make the hospitals a safer place.
Healthcare in the 21st century is a highly complex network of digital systems that link clinics to labs, emergency to radiology and hospitals to hospitals. Physicians and healthcare workers are constantly bombarded by information from different tests, monitors and radiographic imaging. Residents need to keep track of dozens of patients with similar conditions and nurses are often expected to look after too many sick people, each with a slightly different combination of medications.
The overwhelming nature of such a work environment results in stress and underscores our fallibility as human beings to be forgetful and to make careless errors that result in approximately 7,000 medication-related deaths a year.
As we head towards the future, the incorporation of technology into healthcare potentially promises a significant decrease in preventable errors. One facet has been the conversion of paper records such as medical histories, laboratory tests, radiology studies and nursing notes to electronic medical records. The thought is that computerized, legible and well-organized notes would make it easier for workers to utilize them and most importantly, not to lose them. Another aspect would be that the digitization of paper records would allow other applications to make use of a database.
For instance, at some centers the computerized physician order entry (CPOE) system tracks and reviews all physician orders for all patients. Use of this technology for automating and double-checking prescriptions aids clinicians in ensuring proper medications, dosages, drug interactions and patient allergies are reviewed before administration to decrease errors. So far, reports have shown an 86 percent decrease in medication errors.
Even just the incorporation of barcodes has been shown to cut mistakes by 70 percent. Despite these innovative solutions a lot of work still remains. A recent two-year study from the Hospital University of Pennsylvania revealed 22 medication-related errors of which 10 were caused by the technology, and 12 caused by user-interface mistakes. Advances in technology have been a double-edged sword: certain aspects are more efficient and effective while the sophistication and complexity increases the potential for errors to continue.
Resident physicians historically have been known to work long hours. In fact, surgical residents prided themselves for being on-call every other day. But is this safe? Studies have shown that interns made substantially more serious medical errors when they worked frequent shifts of 24 hours or more than when they worked shorter shifts. On a traditional schedule, interns worked an average of 84.9 hours per week. When compared to interns that adopted a reduced schedule of 65.4 hours per week, overworked residents made 35.9 percent more serious medical errors and 20.8 percent more medication errors.
The total rate of serious mistakes in the critical care unit was also 22 percent greater and at night, these residents were twice as likely to miss something. A survey of public concerns identified that 65 percent of Americans feared being given the wrong medicine and 56 percent feared complications from a medical procedure. Considering that residents provide a large amount of these healthcare services, decreasing and enforcing work hours would be another avenue to address medical errors. Some centers have enforced a 65 hour weekly schedule and results have shown a 40 percent decrease in mistakes.
An interesting point is that by decreasing the number of working hours for residents, are mistakes reduced because there simply isn't a resident around to make one? Along with the fact that well-rested interns perform better, another potential explanation is that senior residents and attending physicians are picking up the slack to cover for the missed hours. They are simply better trained, higher educated and more experienced to deal with problems that arise at night when traditionally, interns were left to fend for themselves.
In an ideal world iatrogenic injuries would not exist and physicians would have limitless knowledge and infallible skills. Realistically, healthcare workers are regular people, to which Pope said "To err is to be human."
Given the fact that errors will be committed, the healthcare system has a duty to learn from past mistakes to prevent the same ones from reoccurring. Thus, the prevention of future failures is dependent upon accurate "error-reporting". Two challenges that confront reporting systems are:
1. Enlisting sufficient participation in the error-reporting programs.
2. Building an adequate response system to correct the error and to educate people to ensure future success.
All reporting programs, whether mandatory or voluntary, are perceived to suffer from under-reporting. Errors may be particularly difficult to recognize in healthcare because variations in individual response to treatment is expected. Also, a survey conducted by the Veterans Association reported that doctors and nurses believed most errors were random, isolated incidences that posed no threat to the safety of patients. Furthermore, little public attention is drawn to these problems.
In comparison to errors in aviation, accidents are well-publicized and scrutinized to ensure a cause is defined and steps are made to prevent future occurrences. The medical culture is also to blame for under-reporting. The traditional culture of blaming and shaming' is the most frequently used approach when addressing errors. In most cases, blame is placed on the individual leading to the error as opposed to placing emphasis on learning from the mistake.
The fear of being blamed has proven counter-productive and has indirectly increased medical error since many adhere to an implicit "conspiracy of silence" when problems and close calls arise for fear of reprisal. Legal barriers further stifle the likelihood of a physician from reporting activities directly related to his or her actions. Reporting systems that provide immunity from punishment have shown to produce abundant and accurate information for error analysis.
The Patient Safety and Quality Improvement Act of 2005, was enacted in response to growing concern about patient safety in the United States. The goal of the Act was to improve patient safety by encouraging voluntary and confidential reporting of events that adversely affected patients at a national level. It allowed for the development of Patient Safety Organizations (PSOs) to collect, aggregate, and analyze confidential information reported by health care providers.
By analyzing patient safety event information, PSOs will be able to identify patterns of failures and propose measures to eliminate patient safety risks and hazards. (Hanson 2007) Resolution of the barriers toward effective error-reporting would permit the collection of data that is essential for the understanding of mistakes and for identifying deficiencies in the healthcare system.
Medical errors continue to be a serious problem in the United States costing billions of dollars and killing thousands of people. Although some adverse events are unavoidable complications inherent to treatment, we as physicians must try to eliminate preventable injuries from harming our patients.
Although technology will become more sophisticated, applications to safeguard and double-check the system are evolving. With the aging population, healthcare workers will face an even greater workload necessitating the need for more doctors and nurses. Redefining work hours may help limit errors, as well as the development of new strategies.
Lastly, we must learn from our mistakes and apply this knowledge to prevent future errors from reoccurring. Accurate systems and proper responses will increase our accountability. As we look towards the future, the first principle of medicine still holds true Primum non nocere. (Do no harm)