Medical error: Difference between revisions

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'''Medical errors''' are the preventable incidents which harm patients. Although [[medical malpractice]] ordinarily involves both error and poor patient outcome, medical errors and malpractice are ''not'' the same. In medical malpractice, there is always a component of negligence or failure to meet an acceptable standard of care on the part of the caregiver. In theory, if all caregivers performed within the bounds of professional XXX, the incidence of medical malpractice ''could'' be reduced to zero. Errors, on the other hand, are made by ''every'' health care worker in every hospital and health care facility. In fact, errors are made by the best trained and most intelligent physicians, nurses, and pharmacists even when diigently following the highest standards of care. The reason is straightforward: in any human system, error can occur and therefore, eventually, ''does'' occur. The incidence of error in medical care can be reduced, but never totally eliminated.
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'''Medical errors''' are mistakes that are made in a medical setting. Errors are made by every type of health care worker, and in every hospital and health care facility. In 2001, the U.S. Institute of Medicine estimated that, every year, 44,000–98,000 deaths in the USA were related to medical errors. <ref>[http://www.nap.edu/openbook/0309068371/html/1.html Page 1, ''To Err Is Human: Building a Safer Health System''], Janet Corrigan, Molla S. Donaldson, and Linda T. Kohn, editors,  National Academy Press (April, 2000), 287 pages, ISBN 0309-06837-1
*[http://orsted.nap.edu/openbook/0309068371/gifmid/1.gif Page 1 gif image]</ref>


In one sense, however, there is a difference between human error on the part of medical personel and the term 'medical error'. That difference is a matter of correction before an error results in harm to the patient. Medical errors are actions, or omissions, on the part of physicians, nurses and other caregivers that lead to a suboptimal result for the patient. In other words, an error that is recognized immediately and fully remedied does not go on to have untoward consequences. There are some errors that, once committed, cause irreparable harm, like sudden death or brain damage - but these are the great minority of actions. Ordinarily, a bad result occurs as the result of more than one error, an initial mistake followed by at least one subsequent failure to recognize and counter it.
Errors are not limited to medical workers and may include any decision maker involved in medical care, including the patient themselves. For example, reimbursements by [[medical insurance]] may be poorly structured resulting in less than optimal outcomes.<ref>[http://www.nytimes.com/2009/05/09/business/09relapse.html "Hospitals Pay for Cutting Costly Readmissions"] article by Reed Abelson in ''[[The New York Times]]'' May 8, 2009</ref>


"In 2001, the U.S. Institute of Medicine estimated the risks of medical error-related deaths in the United States to be 44,000–98,000 deaths per year, letting aside other serious adverse events". (reference for quote:Assadian O. Toma CD. Rowley SD. Implications of staffing ratios and workload limitations on healthcare-associated infections and the quality of patient care. Critical Care Medicine. 35(1):296-8, 2007 Jan.
When an error occurs, the key question becomes, will it be recognized and corrected? Errors that eventually result in injury are typically compounded by subsequent errors of not recognizing that an error has occurred, and not taking remedial action.
UI: 17197771)
=On-going strategies for reduction of medical error=
Within the [[health sciences]], there have been varying approaches to reducing medical errors.  


Adaptation of a "pilot's chectlist" to prepare for take-off and landing has been tested for use for usefulness in preparation for the performance of [[Cesarean delivery]] under [[general anesthesia]]. <ref>Hart EM. Owen H. "Errors and omissions in anesthesia: a pilot study using a pilot's checklist", Journal Article. Research Support, Non-U.S. Gov't, ''Anesthesia & Analgesia'', 101(1):246-50, table of contents, 2005 Jul., UI: 15976240</ref>
==Epidemiology/frequency==
Errors may occur among hospitalized patients, ambulatory patients, or patients after discharge from the hospital.<ref name="pmid12558354">{{cite journal |author=Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW |title=The incidence and severity of adverse events affecting patients after discharge from the hospital |journal=Ann. Intern. Med. |volume=138 |issue=3 |pages=161–7 |year=2003 |pmid=12558354 |doi= |issn=}}</ref>


Improvement of medical personel.
The frequency of errors is higher when physicians and patients are asked about their experience with errors among their families.<ref name="pmid12477944">{{cite journal| author=Blendon RJ, DesRoches CM, Brodie M, Benson JM, Rosen AB, Schneider E et al.| title=Views of practicing physicians and the public on medical errors. | journal=N Engl J Med | year= 2002 | volume= 347 | issue= 24 | pages= 1933-40 | pmid=12477944
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12477944 | doi=10.1056/NEJMsa022151 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>


==Reduction of duty hours==
The frequency of meaningful medical error is debated.<ref name="pmid11466119">{{cite journal |author=Hayward RA, Hofer TP |title=Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer |journal=JAMA |volume=286 |issue=4 |pages=415–20 |year=2001 |pmid=11466119 |doi= |issn=}}</ref>


Myers JS. Bellini LM. Morris JB. Graham D. Katz J. Potts JR. Weiner C. Volpp KG. Internal medicine and general surgery residents' attitudes about the ACGME duty hours regulations: a multicenter study.[see comment]. [Journal Article. Multicenter Study. Research Support, U.S. Gov't, Non-P.H.S.] Academic Medicine. 81(12):1052-8, 2006 Dec.
Most patients in [[intensive care]] experience at least one error.<ref name="pmid19875690">{{cite journal| author=Garrouste-Orgeas M, Timsit JF, Vesin A, Schwebel C, Arnodo P, Lefrant JY et al.| title=Selected medical errors in the intensive care unit: results of the IATROREF study: parts I and II. | journal=Am J Respir Crit Care Med | year= 2010 | volume= 181 | issue= 2 | pages= 134-42 | pmid=19875690
UI: 17122468
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19875690 | doi=10.1164/rccm.200812-1820OC }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>


==oversight of professional conduct ==
==Reporting requirements==
In the United States reporting medical errors in hospitals is a condition of payment by Medicare.<ref>[http://www.nytimes.com/2012/01/06/health/study-of-medicare-patients-finds-most-hospital-errors-unreported.html "Report Finds Most Errors at Hospitals Go Unreported"] article by Robert Pear in ''[[The New York Times]]'' January 6, 2012</ref> An investigation by the Office of Inspector General, Department of Health and Human Services released January 6, 2012 found that most errors are not reported and even in the case of errors that are reported and investigated changes are seldom made which would prevent them in the future. The investigation revealed that there was often lack of knowledge regarding which events were reportable and recommended that lists of reportable events be developed. <ref>[http://oig.hhs.gov/oei/reports/oei-06-09-00091.asp Summary "Hospital Incident Reporting Systems Do Not Capture Most Patient Harm"] Report (OEI-06-09-00091) Office of Inspector General, Department of Health and Human Services, January 6, 2012</ref>


==Classification==
Errors can be classified into "no fault," "system-related", and "cognitive".<ref name="pmid16009864">{{cite journal |author=Graber ML, Franklin N, Gordon R |title=Diagnostic error in internal medicine |journal=Arch. Intern. Med. |volume=165 |issue=13 |pages=1493–9 |year=2005 |pmid=16009864 |doi=10.1001/archinte.165.13.1493}}</ref>


===No fault===
Examples including overlooking a disease that in a patient with manifestations so atypical that most doctors would not be expected to recognize the underlying disease.


===Institute for Healthcare Improvement===
===System-related===
The [[Institute for Healthcare Improvement]] (IHI) defines medical harm as "unintended [[physical injury]] resulting from or contributed to by [[medical care]] (including the absence of indicated medical treatment) that requires additional monitoring, treatment or hospitalization, or results in death." Previously, IHI initiated the 100,000 Lives Campaign. That campaign, participated in by 3,200 [[hospital]]s, is estimated to have reduced deaths of patients in hospitals by 122,000 in 18 months. The campaign focused on 6 "interventions" which had been identified as likely to reduce medical error:
Examples of system errors include "problems with policies and procedures, inefficient processes, teamwork, and communication."<ref name="pmid16009864"/> Errors may happen during transfer of care.<ref>Horwitz LI et al. (2008) Dropping the Baton: A Qualitative Analysis of Failures During the Transition From Emergency Department to Inpatient Care. Annals of Emergency Medicine{{doi|10.1016/j.annemergmed.2008.05.007}}</ref> In medical training, breakdowns in teamwork (including supervision) are a cause<ref name="pmid17954795">{{cite journal |author=Singh H, Thomas EJ, Petersen LA, Studdert DM |title=Medical errors involving trainees: a study of closed malpractice claims from 5 insurers |journal=Arch. Intern. Med. |volume=167 |issue=19 |pages=2030–6 |year=2007 |pmid=17954795 |doi=10.1001/archinte.167.19.2030}}</ref><ref name="pmid18779462">{{cite journal |author=Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH |title=Consequences of Inadequate Sign-out for Patient Care |journal=Arch. Intern. Med. |volume=168 |issue=16 |pages=1755–60 |year=2008 |month=September |pmid=18779462 |doi=10.1001/archinte.168.16.1755 |url= |issn=}}</ref>, especially at the beginning of the academic year<ref name="pmid20065752">{{cite journal| author=Inaba K, Recinos G, Teixeira PG, Barmparas G, Talving P, Salim A et al.| title=Complications and death at the start of the new academic year: is there a July phenomenon? | journal=J Trauma | year= 2010 | volume= 68 | issue= 1 | pages= 19-22 | pmid=20065752
<blockquote>
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=20065752 | doi=10.1097/TA.0b013e3181b88dfe }}</ref><ref name="pmid19826176">{{cite journal| author=Haller G, Myles PS, Taffé P, Perneger TV, Wu CL| title=Rate of undesirable events at beginning of academic year: retrospective cohort study. | journal=BMJ | year= 2009 | volume= 339 | issue=  | pages= b3974 | pmid=19826176
#Deploy [[rapid response team|Rapid Response Team]]s… at the first sign of patient decline – and before a catastrophic cardiac or respiratory event.
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19826176 | doi=10.1136/bmj.b3974 }} </ref>.
#Deliver reliable, [[evidence-based medical care|evidence-based care]] for [[acute myocardial infarction]]…to prevent deaths from heart attack.
#Prevent [[adverse drug event]]s…by reconciling patient medications at every transition point in care.
#Prevent [[central line]] [[infection]]s…by implementing a series of interdependent, scientifically grounded steps.
#Prevent [[surgical site infection]]s…by following a series of steps, including reliable, timely administration of correct perioperative antibiotics.
#Prevent [[ventilator-associated pneumonia]]…by implementing a series of interdependent, scientifically grounded steps.</blockquote>


IHI's second campaign, the 5 Million Lives Campaign, <ref>[http://www.ihi.org/IHI/Programs/Campaign5 Million Lives Campaign]</ref> challenges 4,000 hospitals to adopt at least one of twelve interventions: the six original interventions and six more:
Interruptions have a complicated affect on error and cognition.<ref name="pmid21946236">{{cite journal| author=Li SY, Magrabi F, Coiera E| title=A systematic review of the psychological literature on interruption and its patient safety implications. | journal=J Am Med Inform Assoc | year= 2011 | volume=  | issue=  | pages= | pmid=21946236 | doi=10.1136/amiajnl-2010-000024 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21946236 }} </ref>
<blockquote>
#Prevent [[methicillin-resistant Staphylococcus aureus]] (MRSA) infection...by reliably implementing scientifically proven [[infection control practice]]s throughout the hospital
#Reduce harm from [[high-alert medication]]s...starting with a focus on [[anticoagulant]]s, [[sedative]]s, [[narcotic]]s, and [[insulin]]
#Reduce [[surgical complication]]s...by reliably implementing the changes in care recommended by the Surgical Care Improvement Project (SCIP)
#Prevent [[pressure ulcer]]s...by reliably using science-based guidelines for prevention of this serious and common complication
#Deliver reliable, evidence-based care for [[congestive heart failure]]…to reduce readmissions
#Get boards on board…by defining and spreading new and leveraged processes for hospital [[board of directors|boards of directors]], so that they can become far more effective in accelerating the improvement of care


The goal is encourage hospitals to improve their procedure enough to eliminate five million incidents of medical harm during a 24-month period, ending Dec. 9, 2008.
====Unclear instructions to health personnel====
Unclear prose, whether in institutional instructions<ref name="pmid18166759">{{cite journal |author=Wheeler DW, Carter JJ, Murray LJ, ''et al'' |title=The effect of drug concentration expression on epinephrine dosing errors: a randomized trial |journal=Ann. Intern. Med. |volume=148 |issue=1 |pages=11–4 |year=2008 |pmid=18166759 |doi= |issn=}}</ref> or reports<ref name="pmid7563535">{{cite journal |author=Bundens WP, Bergan JJ, Halasz NA, Murray J, Drehobl M |title=The superficial femoral vein. A potentially lethal misnomer |journal=JAMA |volume=274 |issue=16 |pages=1296–8 |year=1995 |pmid=7563535 |doi= |issn=}}</ref><ref name="pmid13678997">{{cite journal |author=Pritchard J, Foley P, Wong H |title=Langerhans and Langhans: what's misleading in a name? |journal=Lancet |volume=362 |issue=9387 |pages=922 |year=2003 |pmid=13678997 |doi=1016/S0140-6736(03)14323-1}}</ref>, may contribute to errors.


=The Patient Advocate=
====Ill-defined clinical flow processes====
Reduction of medical error can be effected on the patient side as well as on the side of the care giver, but only with vigilence on the part of the patient him or herself, or on the part of the patient's advocate.
The results of abnormal [[diagnostic test]]s may not acted upon.<ref name="pmid22183961">{{cite journal| author=Callen JL, Westbrook JI, Georgiou A, Li J| title=Failure to Follow-Up Test Results for Ambulatory Patients: A Systematic Review. | journal=J Gen Intern Med | year= 2011 | volume=  | issue=  | pages=  | pmid=22183961 | doi=10.1007/s11606-011-1949-5 | pmc= | url= }} </ref><ref name="pmid22122864">{{cite journal| author=Davis Giardina T, Singh H| title=Should patients get direct access to their laboratory test results? An answer with many questions. | journal=JAMA | year= 2011 | volume= 306 | issue= 22 | pages= 2502-3 | pmid=22122864 | doi=10.1001/jama.2011.1797 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22122864  }} </ref>


====Work load====
Examining errors in administration of parenteral [[medication]]s in [[intensive care]], a study found:<ref name="pmid19282436">{{cite journal |author=Valentin A, Capuzzo M, Guidet B, ''et al'' |title=Errors in administration of parenteral drugs in intensive care units: multinational prospective study |journal=BMJ |volume=338 |issue= |pages=b814 |year=2009 |pmid=19282436 |doi= |url=http://bmj.com/cgi/pmidlookup?view=long&pmid=19282436 |issn=}}</ref>
* 74 errors per 100 patient-days
* Independent risk factors were:
** Patient complexity as measured by
*** number of organ failures
*** number of parenteral administrations
** Work load as measured by
*** Larger intensive care unit
*** Increased ratio of patient turnover to the size of the unit
*** Number of patients per nurse
*** Occupancy rate of the unit


Workload may also be associated with adverse outcomes in emergency rooms.<ref>{{Cite journal
| doi = 10.1056/NEJMoa1009370
| issn = 0028-4793
| pages = 110601140030042
| last = Arora
| first = Sanjeev
| coauthors = Karla Thornton, Glen Murata, Paulina Deming, Summers Kalishman, Denise Dion, Brooke Parish, Thomas Burke, Wesley Pak, Jeffrey Dunkelberg, Martin Kistin, John Brown, Steven Jenkusky, Miriam Komaromy, Clifford Qualls
| title = Outcomes of Treatment for Hepatitis C Virus Infection by Primary Care Providers
| journal = New England Journal of Medicine
| accessdate = 2011-06-02
| date = 2011-06
| url = http://www.nejm.org/doi/full/10.1056/NEJMoa1009370
}}</ref>


On the other hand, insufficient volume of care is associated with reduced quality of care.<ref name="pmid19934421">{{cite journal| author=Kumbhani DJ, Cannon CP, Fonarow GC, Liang L, Askari AT, Peacock WF et al.| title=Association of hospital primary angioplasty volume in ST-segment elevation myocardial infarction with quality and outcomes. | journal=JAMA | year= 2009 | volume= 302 | issue= 20 | pages= 2207-13 | pmid=19934421
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19934421 | doi=10.1001/jama.2009.1715 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>


==Notes==
====Inadequate staffing====
<references/>
Many studies show that adverse events are associated with low staffing.<ref name="pmid18584502">{{cite journal |author=Liu JM, Yang Q, Pirrallo RG, Klein JP, Aufderheide TP |title=Hospital variability of out-of-hospital cardiac arrest survival |journal=Prehosp Emerg Care |volume=12 |issue=3 |pages=339–46 |year=2008 |pmid=18584502 |doi=10.1080/10903120802101330 |url=http://www.informaworld.com/openurl?genre=article&doi=10.1080/10903120802101330&magic=pubmed||1B69BA326FFE69C3F0A8F227DF8201D0 |issn=}}</ref><ref name="pmid11271096">{{cite journal |author=Amaravadi RK, Dimick JB, Pronovost PJ, Lipsett PA |title=ICU nurse-to-patient ratio is associated with complications and resource use after esophagectomy |journal=Intensive Care Med |volume=26 |issue=12 |pages=1857–62 |year=2000 |month=December |pmid=11271096 |doi= |url=http://link.springer-ny.com/link/service/journals/00134/bibs/0026012/00261857.htm |issn=}}</ref><ref name="pmid12657982">{{cite journal |author=Cho SH, Ketefian S, Barkauskas VH, Smith DG |title=The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs |journal=Nurs Res |volume=52 |issue=2 |pages=71–9 |year=2003 |pmid=12657982 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0029-6562&volume=52&issue=2&spage=71 |issn=}}</ref>
 
====Weekends and off hours====
Inadequate provision of medical care for patients admitted on weekends may increase adverse outcomes in most<ref name="pmid17466653">{{cite journal |author=Bendavid E, Kaganova Y, Needleman J, Gruenberg L, Weissman JS |title=Complication rates on weekends and weekdays in US hospitals |journal=Am. J. Med. |volume=120 |issue=5 |pages=422–8 |year=2007 |month=May |pmid=17466653 |doi=10.1016/j.amjmed.2006.05.067 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9343(06)00894-1 |issn=}}</ref><ref name="pmid16106005">{{cite journal |author=Magid DJ, Wang Y, Herrin J, ''et al'' |title=Relationship between time of day, day of week, timeliness of reperfusion, and in-hospital mortality for patients with acute ST-segment elevation myocardial infarction |journal=JAMA |volume=294 |issue=7 |pages=803–12 |year=2005 |month=August |pmid=16106005 |doi=10.1001/jama.294.7.803 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=16106005 |issn=}}</ref><ref name="pmid17360988">{{cite journal |author=Kostis WJ, Demissie K, Marcella SW, Shao YH, Wilson AC, Moreyra AE |title=Weekend versus weekday admission and mortality from myocardial infarction |journal=N. Engl. J. Med. |volume=356 |issue=11 |pages=1099–109 |year=2007 |pmid=17360988 |doi=10.1056/NEJMoa063355}}</ref><ref name="pmid15276592">{{cite journal |author=Cram P, Hillis SL, Barnett M, Rosenthal GE |title=Effects of weekend admission and hospital teaching status on in-hospital mortality |journal=Am. J. Med. |volume=117 |issue=3 |pages=151–7 |year=2004 |pmid=15276592 |doi=10.1016/j.amjmed.2004.02.035}}</ref><ref name="pmid11547721">{{cite journal |author=Bell CM, Redelmeier DA |title=Mortality among patients admitted to hospitals on weekends as compared with weekdays |journal=N. Engl. J. Med. |volume=345 |issue=9 |pages=663–8 |year=2001 |pmid=11547721 |doi=}}</ref><ref name="pmid18285590">{{cite journal |author=Peberdy MA, Ornato JP, Larkin GL, ''et al'' |title=Survival from in-hospital cardiac arrest during nights and weekends |journal=JAMA : the journal of the American Medical Association |volume=299 |issue=7 |pages=785–92 |year=2008 |month=February |pmid=18285590 |doi=10.1001/jama.299.7.785 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=18285590 |issn=}}</ref> but not all<ref name="pmid12799403">{{cite journal |author=Gould JB, Qin C, Marks AR, Chavez G |title=Neonatal mortality in weekend vs weekday births |journal=JAMA |volume=289 |issue=22 |pages=2958–62 |year=2003 |pmid=12799403 |doi=10.1001/jama.289.22.2958}}</ref> studies. The same may be true for in-hospital cardiac arrest.<ref name="pmid18285590"/> "The [[weekend effect]] was larger in major [[teaching hospital]]s compared with nonteaching hospitals."<ref name="pmid15276592">{{cite journal |author=Cram P, Hillis SL, Barnett M, Rosenthal GE |title=Effects of weekend admission and hospital teaching status on in-hospital mortality |journal=Am. J. Med. |volume=117 |issue=3 |pages=151–7 |year=2004 |pmid=15276592 |doi=10.1016/j.amjmed.2004.02.035}}</ref>
 
The reduced quality of care during off hours may improve as a hospital has more experience in quality improvement.<ref name="pmid18988914">{{Cite journal
| doi = 10.1161/STROKEAHA.108.519355
| issn = 1524-4628
| volume = 40
| issue = 2
| pages = 569-576
| last = Reeves
| first = Mathew J
| coauthors = Eric Smith, Gregg Fonarow, Adrian Hernandez, Wenqin Pan, Lee H Schwamm
| title = Off-hour admission and in-hospital stroke case fatality in the get with the guidelines-stroke program
| journal = Stroke; a Journal of Cerebral Circulation
| accessdate = 2009-09-01
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| pmid=18988914
}}</ref>
 
====Failure to rescue====
Hospitals have similar incidence of surgical complications, yet varying incidence of nosocomial death. This suggests that some hospitals have a "failure to rescue" patients from complications.<ref name="pmid19797283">{{cite journal| author=Ghaferi AA, Birkmeyer JD, Dimick JB| title=Variation in hospital mortality associated with inpatient surgery. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 14 | pages= 1368-75 | pmid=19797283
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19797283 | doi=10.1056/NEJMsa0903048 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>
 
====Hospital discharge====
{{main|Patient discharge}}
 
===Cognitive===
Voytovich has suggested that [[diagnostic error]] due to cognitive errors can be further classified into omission of finding, premature closure, inadequate synthesis, and wrong formulation.<ref name="pmid3736379">{{cite journal |author=Dubeau CE, Voytovich AE, Rippey RM |title=Premature conclusions in the diagnosis of iron-deficiency anemia: cause and effect |journal=Medical decision making : an international journal of the Society for Medical Decision Making |volume=6 |issue=3 |pages=169–73 |year=1986 |pmid=3736379 |doi=}}</ref> Similarly, Graber has classified cognitive error into faulty knowledge, faulty data gathering, and faulty synthesis (usually premature closure).<ref name="pmid16009864">{{cite journal |author=Graber ML, Franklin N, Gordon R |title=Diagnostic error in internal medicine |journal=Arch. Intern. Med. |volume=165 |issue=13 |pages=1493–9 |year=2005 |pmid=16009864 |doi=10.1001/archinte.165.13.1493}}</ref> An additional classification has been proposed by Kassirer.<ref name="pmid2648823">{{cite journal |author=Kassirer JP, Kopelman RI |title=Cognitive errors in diagnosis: instantiation, classification, and consequences |journal=Am. J. Med. |volume=86 |issue=4 |pages=433–41 |year=1989 |pmid=2648823 |doi=}}</ref> In medical trainees, cognitive errors are an important cause or medical error.<ref name="pmid17954795">{{cite journal |author=Singh H, Thomas EJ, Petersen LA, Studdert DM |title=Medical errors involving trainees: a study of closed malpractice claims from 5 insurers |journal=Arch. Intern. Med. |volume=167 |issue=19 |pages=2030–6 |year=2007 |pmid=17954795 |doi=10.1001/archinte.167.19.2030}}</ref> The many cognitive biases that can lead to cognitive error have been inventoried.<ref name="pmid12414468">{{cite journal |author=Croskerry P |title=Achieving quality in clinical decision making: cognitive strategies and detection of bias |journal=Academic emergency medicine : official journal of the Society for Academic Emergency Medicine |volume=9 |issue=11 |pages=1184–204 |year=2002 |pmid=12414468 |doi=}}</ref><ref name="pmid22218629">{{cite journal| author=Ely JW, Kaldjian LC, D'Alessandro DM| title=Diagnostic errors in primary care: lessons learned. | journal=J Am Board Fam Med | year= 2012 | volume= 25 | issue= 1 | pages= 87-97 | pmid=22218629 | doi=10.3122/jabfm.2012.01.110174 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22218629  }} </ref>
 
=====Omission of finding=====
An example is recording a finding during data collection, but not including the finding on the problem list.<ref name="pmid3736379"/>
 
=====Faulty data gathering=====
An example of faulty data gathering is and incomplete physical examination or not ordering needed tests.<ref name="pmid16009864"/>
 
=====Premature closure=====
Premature closure is the most common cognitive error.<ref name="pmid16009864"/><ref name="pmid3736379">{{cite journal |author=Dubeau CE, Voytovich AE, Rippey RM |title=Premature conclusions in the diagnosis of iron-deficiency anemia: cause and effect |journal=Medical decision making : an international journal of the Society for Medical Decision Making |volume=6 |issue=3 |pages=169–73 |year=1986 |pmid=3736379 |doi=}}</ref>
 
=====Wrong formulation=====
Examples of wrong formulation or flawed reasoning are making a diagnosis that is contradicted by clinical findings.
 
=====Inadequate knowledge=====
Inadequate knowledge can be a factor<ref name="pmid12377672">{{cite journal |author=Graber M, Gordon R, Franklin N |title=Reducing diagnostic errors in medicine: what's the goal? |journal=Academic medicine : journal of the Association of American Medical Colleges |volume=77 |issue=10 |pages=981–92 |year=2002 |pmid=12377672 |doi=}}</ref>, but is uncommon as an isolated problem in studies of causes of medical errors.<ref name="pmid16009864">{{cite journal |author=Graber ML, Franklin N, Gordon R |title=Diagnostic error in internal medicine |journal=Arch. Intern. Med. |volume=165 |issue=13 |pages=1493–9 |year=2005 |pmid=16009864 |doi=10.1001/archinte.165.13.1493}}</ref> However, inadequate knowledge was found to be a more common problem in study of appropriateness of care among patients without identified medical errors.<ref name="pmid15109337">{{cite journal |author=Lucas BP, Evans AT, Reilly BM, ''et al'' |title=The impact of evidence on physicians' inpatient treatment decisions |journal=Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine |volume=19 |issue=5 Pt 1 |pages=402–9 |year=2004 |pmid=15109337 |doi=10.1111/j.1525-1497.2004.30306.x}}</ref> It is unclear how often each of the types of cognitive errors such as an incomplete evaluation, omission of a finding, wrong formulation, are partly due to inadequate knowledge of diseases.
 
===System-related cognitive deficits===
At the interface between system-related errors and cognitive errors, one finds the errors that are learnt in the course of the formative years, in medical schools.
 
Needless to say, doctors are expected to have a very high degree of moral development: the profession requires an ability to make choices that will impact on the quality of life of innumerable patients, and to act appropriately and diligently when faced with life-or-death situations. Doctors are expected to master an enormous amount of knowledge, and to advance beyond when faced with the grey areas of clinical practice.
 
It is recognized that higher education has a favourable impact on moral development: university students tend to reason more in societal and principled terms when faced with ethical issues, and less in terms of self-interest or peer approval, the more they advance in their university curriculum. The medical curriculum is a notable exception to this rule.
 
It is now recognized that medical education, as it is today, hinders moral development.<ref name="pmid8487415">{{cite journal |author=Crandall SJ, Volk RJ, Loemker V |title=Medical students' attitudes toward providing care for the underserved. Are we training socially responsible physicians? |journal=JAMA |volume=269 |issue=19 |pages=2519–23 |year=1993 |month=May |pmid=8487415 |doi= |url=}} In this study, only male medical students were found to be handicapped in their moral reasoning.</ref><ref name="pmid10724311">{{cite journal |author=Osborn E |title=Punishment: a story for medical educators |journal=Acad Med |volume=75 |issue=3 |pages=241–4 |year=2000 |month=March |pmid=10724311 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=1040-2446&volume=75&issue=3&spage=241}}This analysis focuses on the enforcement by medical schools of a logic of factual accuracy to the detriment of creative thinking.</ref><ref name="pmid1404281">{{cite journal |author=Hébert PC, Meslin EM, Dunn EV |title=Measuring the ethical sensitivity of medical students: a study at the University of Toronto |journal=J Med Ethics |volume=18 |issue=3 |pages=142–7 |year=1992 |month=September |pmid=1404281 |pmc=1376259 |doi= |url=http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=1404281}}Ethical sensitivity and moral reasoning ability are two distinct endpoints. This study deals with the former only.</ref>The reason why medical education forms doctors that will be less able to take ethical decisions than other professionals with comparable levels of education is still not known with certainty, although the so-called "hidden curriculum"<ref>The "hidden curriculum" is the whole set of attitudes and mindsets that are promoted implicitely by teachers. The importance of the hidden curriculum was eloquently expressed by Dr Albert Schweitzer: "Example is not the main thing in influencing others. It's the only thing".</ref> appears to be a likely culprit.<ref name="pmid12668541">{{cite journal |author=Patenaude J, Niyonsenga T, Fafard D |title=Changes in students' moral development during medical school: a cohort study |journal=CMAJ |volume=168 |issue=7 |pages=840–4 |year=2003 |month=April |pmid=12668541 |pmc=151989 |doi= |url=http://www.cmaj.ca/cgi/pmidlookup?view=long&pmid=12668541}}</ref>
 
===Patient related===
Patients who have more medical problems<ref name="pmid9593791">{{cite journal| author=Redelmeier DA, Tan SH, Booth GL| title=The treatment of unrelated disorders in patients with chronic medical diseases. | journal=N Engl J Med | year= 1998 | volume= 338 | issue= 21 | pages= 1516-20 | pmid=9593791
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9593791 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref> and more complaints<ref name="pmid17548846">{{cite journal| author=Parchman ML, Pugh JA, Romero RL, Bowers KW| title=Competing demands or clinical inertia: the case of elevated glycosylated hemoglobin. | journal=Ann Fam Med | year= 2007 May-Jun | volume= 5 | issue= 3 | pages= 196-201 | pmid=17548846
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17548846 | doi=10.1370/afm.679 | pmc=PMC1886492 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref> may have reduced quality of care due to competing demands on physician time.
 
==Malpractice==
{{main|Medical malpractice}}
If an error involves [[negligence]] and results in [[damage]], as those terms are legally defined, it may be treated as [[medical malpractice]] and result in substantial liability. The possibility of legal liability can be a barrier to free discussion and disclosure of medical error, hampering efforts to reduce error. Thus, provisions for confidential reporting of errors can be useful.
 
==Prevention==
===Lessons from aviation===
Plane crashes can be dramatic events, causing considerable loss of life and attracting wide publicity damaging to the reputation of the airlines involved, and weakening passenger confidence in air travel. Accordingly, all plane crashes and related serious incidents ("near misses") are exhaustively investigated in an effort to establish their precise causes. By comparison, most medical errors do not have the same wide impact, thus they seldom receive such intense scrutiny and analysis. <ref> Robert L Helmreich RL (2000) On error management: lessons from aviation. ''BMJ''[http://www.bmj.com/cgi/content/full/320/7237/781 320:781-5]</ref>
 
An adapted version of a  "pilot's checklist" (designed to ensure that safety procedures are rigorously followed when preparing for take-off and landing) has been tested for usefulness in preparation for performing [[Cesarean delivery]] under [[general anesthesia]]. <ref>Hart EM, Owen H (2005) Errors and omissions in anesthesia: a pilot study using a pilot's checklist. ''Anesthesia & Analgesia'' 101:246-50 PMID 15976240</ref>
 
Another aviation safety method, with potential healthcare benefit, is [[crew resource management]] (CRM), also called cockpit resource management. While the captain of an aircraft is the ultimate authority, CRM helps ensure that all crew members are proactive in sharing safety-related information. <ref name=CRM-AHRQ>{{citation
| contribution = Chapter 44. Crew Resource Management and its Applications in Medicine
| first1 = Laura | last1 = Pizzi | first2 = Neil I. |last2 = Goldfarb | first3 = David B. | last3= Nash
| date = July 2001
| title = Making Health Care Safer: A Critical Analysis of Patient Safety Practices
| publisher = Agency for Healthcare Research and Quality
| id = Evidence Report/Technology Assessment, No. 43
| url = http://www.ahrq.gov/clinic/ptsafety/chap44.htm}}</ref>  Some of CRM principles include peer monitoring, acceptance that team members do make errors, and that each team member has responsibility both for the patient and for situational awareness. The method cannot be transferred directly to medicine, but has potential to be modified to medicine.
 
Some of the differences include that cockpit crew are usually all certified pilots with differing levels of experience in the same basic skill set, while healthcare teams involve people not only with different levels of experience, but different skills and lack of skills. A surgeon may not have the physiologic intuition of an anesthesiologist, but the surgeon is the authority. An experienced surgical nurse may see a young surgeon about to make an error, but a concept of nurse vs. physician roles may reduce the chance of a warning being issued, or perhaps being accepted.
 
Aviators also have one motivator that is far less common than in medicine: shared fate.  While a break in barrier methods may infect a healthcare team member, the implications are not as drastic as the failure of a copilot to assert the aircraft did not have adequate takeoff speed, which should have caused the takeoff to be aborted, rather than Air Florida 93 crashing into the 14th Street Bridge in Washington DC.
 
===Hospital design===
See also: [[electronic medical record]], [[electronic health record]], [[clinical decision support system]], and [[medical order entry system]].
 
Patients placed in isolation rooms for infection control "experience more preventable adverse events, express greater dissatisfaction with their treatment, and have less documented care."<ref name="pmid14532319">{{cite journal |author=Stelfox HT, Bates DW, Redelmeier DA |title=Safety of patients isolated for infection control |journal=JAMA |volume=290 |issue=14 |pages=1899–905 |year=2003 |pmid=14532319 |doi=10.1001/jama.290.14.1899}}</ref>
 
Bar coding medication administration may reduce errors.<ref>{{Cite journal
| doi = 10.1056/NEJMsa0907115
| volume = 362
| issue = 18
| pages = 1698-1707
| last = Poon
| first = Eric G.
| coauthors = Carol A. Keohane, Catherine S. Yoon, Matthew Ditmore, Anne Bane, Osnat Levtzion-Korach, Thomas Moniz, Jeffrey M. Rothschild, Allen B. Kachalia, Judy Hayes, William W. Churchill, Stuart Lipsitz, Anthony D. Whittemore, David W. Bates, Tejal K. Gandhi
| title = Effect of Bar-Code Technology on the Safety of Medication Administration
| journal = N Engl J Med
| accessdate = 2010-05-06
| date = 2010-05-06
| url = http://content.nejm.org/cgi/content/abstract/362/18/1698
}}</ref>
 
===Personnel factors===
 
====Sleep deprivation====
Sleep deprivation may contribute to errors.<ref name="pmid19826026">{{cite journal| author=Rothschild JM, Keohane CA, Rogers S, Gardner R, Lipsitz SR, Salzberg CA et al.| title=Risks of complications by attending physicians after performing nighttime procedures. | journal=JAMA | year= 2009 | volume= 302 | issue= 14 | pages= 1565-72 | pmid=19826026
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19826026 | doi=10.1001/jama.2009.1423 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>
 
====Reduction of duty hours====
: ''See also [[Medical education]]''
 
A survey of 200 residents who trained both before and after duty hours reform reported improved quality of life. However, "Residents reported that whereas fatigue-related errors decreased slightly, errors related to reduced continuity of care significantly increased." <ref>Myers JS ''et al.'' (2006)[http://www.academicmedicine.org/pt/re/acmed/abstract.00001888-200612000-00008.htm;jsessionid=FQcJD097zG906SjRx5pVNhm2Y2QNgQCpPyyQ3hLvyWJHzRdpLG3k!2089961419!-949856144!8091!-1 Internal medicine and general surgery residents' attitudes about the ACGME duty hours regulations: a multicenter study], ''Academic Medicine'' 81:1052-8, PMID 17122468</ref> Resident believe excessive work hours is a common cause of medical error.<ref name="pmid16344418">{{cite journal |author=Jagsi R, Kitch BT, Weinstein DF, Campbell EG, Hutter M, Weissman JS |title=Residents report on adverse events and their causes |journal=Arch. Intern. Med. |volume=165 |issue=22 |pages=2607–13 |year=2005 |pmid=16344418 |doi=10.1001/archinte.165.22.2607 |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=16344418 |issn=}}</ref><ref name="pmid17356987">{{cite journal |author=Vidyarthi AR, Auerbach AD, Wachter RM, Katz PP |title=The impact of duty hours on resident self reports of errors |journal=J Gen Intern Med |volume=22 |issue=2 |pages=205–9 |year=2007 |month=February |pmid=17356987 |pmc=1824755 |doi=10.1007/s11606-006-0065-4 |url=http://dx.doi.org/10.1007/s11606-006-0065-4 |issn=}}</ref><ref name="pmid17194188">{{cite journal |author=Barger LK, Ayas NT, Cade BE, ''et al'' |title=Impact of extended-duration shifts on medical errors, adverse events, and attentional failures |journal=PLoS Med. |volume=3 |issue=12 |pages=e487 |year=2006 |month=December |pmid=17194188 |pmc=1705824 |doi=10.1371/journal.pmed.0030487 |url=http://dx.plos.org/10.1371/journal.pmed.0030487 |issn=}}</ref>
 
Restricting duty hours may<ref name="pmid17976424">{{cite journal |author=Bhavsar J, Montgomery D, Li J, ''et al'' |title=Impact of duty hours restrictions on quality of care and clinical outcomes |journal=Am. J. Med. |volume=120 |issue=11 |pages=968–74 |year=2007 |month=November |pmid=17976424 |doi=10.1016/j.amjmed.2007.07.026 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9343(07)00738-3 |issn=}}</ref><ref name="pmid17548403">{{cite journal |author=Shetty KD, Bhattacharya J |title=Changes in hospital mortality associated with residency work-hour regulations |journal=Ann. Intern. Med. |volume=147 |issue=2 |pages=73–80 |year=2007 |month=July |pmid=17548403 |doi= |url= |issn=}}</ref><ref name="pmid17785643">{{cite journal |author=Volpp KG, Rosen AK, Rosenbaum PR, ''et al'' |title=Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform |journal=JAMA |volume=298 |issue=9 |pages=984–92 |year=2007 |month=September |pmid=17785643 |doi=10.1001/jama.298.9.984 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=17785643 |issn=}}</ref> or may not<ref name="pmid17785642">{{cite journal |author=Volpp KG, Rosen AK, Rosenbaum PR, ''et al'' |title=Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform |journal=JAMA |volume=298 |issue=9 |pages=975–83 |year=2007 |month=September |pmid=17785642 |doi=10.1001/jama.298.9.975 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=17785642 |issn=}}</ref> improve performance. However, restrictions may be costly.<ref name="pmid19458365">{{cite journal |author=Nuckols TK, Bhattacharya J, Wolman DM, Ulmer C, Escarce JJ |title=Cost implications of reduced work hours and workloads for resident physicians |journal=N. Engl. J. Med. |volume=360 |issue=21 |pages=2202–15 |year=2009 |month=May |pmid=19458365 |doi=10.1056/NEJMsa0810251 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=19458365&promo=ONFLNS19 |issn=}}</ref>
 
====Oversight of professional conduct ====
It is not clear that the oversight of professional conduct prevents errors.
 
===Organizations promoting error reduction===
 
====Institute for Healthcare Improvement====
The [http://www.ihi.org Institute for Healthcare Improvement] (IHI) defines medical harm as "unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment) that requires additional monitoring, treatment or hospitalization, or results in death."
 
;100,000 Lives Campaign
In 2004, the IHI initiated the 100,000 Lives Campaign.<ref name="pmid16418469">{{cite journal |author=Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD |title=The 100,000 lives campaign: setting a goal and a deadline for improving health care quality |journal=JAMA |volume=295 |issue=3 |pages=324–7 |year=2006 |pmid=16418469 |doi=10.1001/jama.295.3.324}}</ref><ref name="titleInstitute for Healthcare Improvement: Overview of the 100,000 Lives Campaign">{{cite web |url=http://www.ihi.org/IHI/Programs/Campaign/100kCampaignOverviewArchive.htm |title=Institute for Healthcare Improvement: Overview of the 100,000 Lives Campaign |accessdate=2008-01-03 |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote=}}</ref> That campaign, participated in by 3,200 hospitals, is estimated to have reduced deaths of patients in hospitals by 122,000 in 18 months. The campaign focused on six "interventions", three focused on common hospital-acquired (''[[nosocomial infection]]s''), which had been identified as likely to reduce medical error:
# "Deploy Rapid Response Teams…at the first sign of patient decline". Rapid Response Teams (RRSs) are teams of critical care experts. Use of Rapid Response Teams has increased dramatically in U.S. Hospitals, from near zero in 2003 to 1500 in 2006. <ref name="2007 Report">[http://www.ihi.org/NR/rdonlyres/858C562A-A535-4344-9573-3AACD1E01CA1/0/2007ProgressReportFINAL.pdf “Status Quon’t”, IHI’s 2007 Progress Report (PDF file)]</ref> RRSs have been helpful in some<ref name="pmid20624835">{{cite journal| author=Lighthall GK, Parast LM, Rapoport L, Wagner TH| title=Introduction of a rapid response system at a United States veterans affairs hospital reduced cardiac arrests. | journal=Anesth Analg | year= 2010 | volume= 111 | issue= 3 | pages= 679-86 | pmid=20624835 | doi=10.1213/ANE.0b013e3181e9c3f3 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20624835  }} </ref>, but not all studies.<ref name="pmid18081187">{{cite journal |author=Ranji SR, Auerbach AD, Hurd CJ, O'Rourke K, Shojania KG |title=Effects of rapid response systems on clinical outcomes: systematic review and meta-analysis |journal=J Hosp Med |volume=2 |issue=6 |pages=422–32 |year=2007 |pmid=18081187 |doi=10.1002/jhm.238}}</ref><ref name="pmid20065195">{{cite journal| author=Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C| title=Rapid Response Teams: A Systematic Review and Meta-analysis. | journal=Arch Intern Med | year= 2010 | volume= 170 | issue= 1 | pages= 18-26 | pmid=20065195
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=20065195 | doi=10.1001/archinternmed.2009.424 }}</ref>
# "Deliver Reliable, Evidence-Based Care for Acute [[Myocardial infarction|Myocardial Infarction]]…to prevent deaths from heart attack."
# "Prevent [[Drug-related side effects and adverse reactions|Adverse Drug Events]] (ADEs)…by implementing medication reconciliation."<ref name="pmid19398689">{{cite journal |author=Schnipper JL, Hamann C, Ndumele CD, ''et al.'' |title=Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial |journal=Arch. Intern. Med. |volume=169 |issue=8 |pages=771–80 |year=2009 |month=April |pmid=19398689 |doi=10.1001/archinternmed.2009.51 |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=19398689 |issn=}}</ref><ref name="pmid19189907">{{cite journal |author=Jack BW, Chetty VK, Anthony D, ''et al.'' |title=A reengineered hospital discharge program to decrease rehospitalization: a randomized trial |journal=Ann. Intern. Med. |volume=150 |issue=3 |pages=178–87 |year=2009 |month=February |pmid=19189907 |doi= |url=http://www.annals.org/cgi/pmidlookup?view=long&pmid=19189907 |issn=}}</ref>
# "Prevent [[central venous catheter|Central Line]] Infections…by implementing a series of interdependent, scientifically grounded steps called the "Central Line Bundle"."
# "Prevent Surgical Site Infections…by reliably delivering the correct perioperative antibiotics at the proper time." Significant reduction may be achieved by procedures as simple as proper hand washing, use of clippers rather than razors to shave the site of surgery, or prompt administration of [[antibiotic]]s following surgery.<ref name="2007 Report"/><ref>[http://www.medscape.com/viewarticle/535487 "Nosocomial Infection: Approach to Postoperative Symptoms of Infection"], From ACS Surgery Online, Posted 06/07/2006, E. Patchen Dellinger, M.D., F.A.C.S.</ref>
# "Prevent Ventilator-Associated [[Pneumonia]]…by implementing a series of interdependent, scientifically grounded steps including the 'Ventilator Bundle'."
 
;5 Million Lives Campaign
IHI's second campaign, the 5 Million Lives Campaign,  <ref name="titleInstitute for Healthcare Improvement: Campaign">{{cite web |url=http://www.ihi.org/IHI/Programs/Campaign |title=Institute for Healthcare Improvement: Campaign |accessdate=2008-01-03 |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote=}}</ref> aims to eliminate five million incidents of medical harm during a 24-month period, ending Dec. 9, 2008. The campaign challenges 4,000 hospitals to adopt at least one of twelve interventions: the six original interventions and the following six more: <ref>[http://www.ihi.org/IHI/Programs/Campaign/Campaign.htm?TabId=1 "Overview of the 5 Million Lives Campaign"]</ref> <ref>[http://www.infectioncontroltoday.com/hotnews/6ch127223175711.html "IHI Launches National Initiative to Reduce Medical Harm in U.S. Hospitals, Builds on 100,000 Lives Campaign"] ''Infection Control Today'', December 12, 2006</ref>
# "Prevent Harm from High-Alert [[Medication]]s... starting with a focus on [[anticoagulant]]s, [[sedative]]s, [[narcotic]]s, and [[insulin]]."
# "Reduce Surgical Complications... by reliably implementing all of the changes in care recommended by SCIP, the Surgical Care Improvement Project (http://www.medqic.org/scip)."
# "Prevent Pressure Ulcers... by reliably using science-based guidelines for their prevention."
# "Reduce Methicillin-Resistant [[Staphylococcus aureus]] (MRSA) infection…by reliably implementing scientifically proven infection control practices."
# "Deliver Reliable, Evidence-Based Care for [[heart failure|Congestive Heart Failure]]... to avoid readmissions."
# "[http://www.ihi.org/IHI/Programs/Campaign/BoardsonBoard.htm Get Boards on Board] … by defining and spreading the best-known leveraged processes for hospital Boards of Directors, so that they can become far more effective in accelerating organizational progress toward safe care."
 
====Agency for Healthcare Research Quality====
The American [[Agency for Healthcare Research and Quality]] has established 11 priority areas:<ref name="titleClear Opportunities for Safety Improvement">{{cite web |url=http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1.section.86592 |title=Clear Opportunities for Safety Improvement |accessdate=2008-02-12 |date=2001|format= |work=|publisher=Agency for Healthcare Research Quality}}</ref>
# Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk.
# Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality.
# Use of maximum sterile barriers while placing central intravenous catheters to prevent infections.
# Appropriate use of antibiotic prophylaxis in surgical patients to prevent perioperative infections.
# Asking that patients recall and restate what they have been told during the informed consent process.
# Continuous aspiration of subglottic secretions (CASS) to prevent ventilator-associated pneumonia.
# Use of pressure relieving bedding materials to prevent pressure ulcers.
# Use of real-time ultrasound guidance during central line insertion to prevent complications.
# Patient self-management for warfarin (CoumadinTM) to achieve appropriate outpatient anticoagulation and prevent complications.
# Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients.
# Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections.
 
====Joint Commission====
The [http://www.jointcommission.org/ Joint Commission] promotes a number of goals that are listed at http://www.jcrinc.com/National-Patient-Safety-Goals/.
 
====United States Surgeon General====
The [[United States of America]] [[Surgeon General]] has announced [http://www.surgeongeneral.gov/library/calls/ calls to action] to improve medical care in the following areas:
* Prevent [[Deep venous thrombosis | Deep Vein Thrombosis]] and [[Pulmonary embolism | Pulmonary Embolism]]
* Prevent and Reduce Underage Drinking
* The Surgeon General’s Call to Action to Improve the Health and Wellness of Persons with Disabilities
* National Call To Action To Promote Oral Health
* Prevent and Decrease Overweight and [[Obesity]]
* Promote Sexual Health and Responsible Sexual Behavior
* Prevent Suicide
 
===The Patient Advocate===
Reduction of medical error can be effected on the patient side as well as on the side of the care giver, but only with vigilance on the part of the patient him or herself, or on the part of the patient's advocate.
 
==Payment==
Generally medical treatment to correct medical error has been considered billable, but effective October 1, 2008 [[Medicare]] will discontinue paying hospitals for treatment resulting from 10 common medical errors. Other insurance carriers are expected to follow suit.<ref>{{cite news
|url=http://www.nytimes.com/2007/08/19/washington/19hospital.html
|title=Medicare Says It Won’t Cover Hospital Errors 
|publisher=The New York Times
|date=2007-08-18
|accessdate=2008-10-01
|first=Robert
|last=Pear
|coauthors=
}}</ref><ref>{{cite news
|url=http://www.nytimes.com/2008/10/01/us/01mistakes.html
|title=Medicare Won’t Pay for Medical Errors 
|publisher=The New York Times
|date=2008-09-30
|accessdate=2008-10-01
|first=Kevin
|last=Sack
|coauthors=
}}</ref><ref>{{cite news
|url=http://www.nytimes.com/imagepages/2008/10/01/us/01mistakes.web.html
|title=Preventable conditions 
|publisher=The New York Times
|date=2008-09-30
|accessdate=2008-10-01
|first=
|last=
|coauthors=
}}</ref> In addition to 7 other conditions, the errors which not will be paid for include three "never events": objects left in the body during surgery, air embolisms and blood incompatibility.<ref>{{cite news
|url=http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=54758
|title=Medicare | Medicare Stops Paying for 10 Reasonably Preventable Medical Errors 
|publisher=Kaiser Daily Health Policy Report
|date=2008-10-01
|accessdate=2008-10-01
|first=
|last=
|coauthors=
}}</ref>
 
==Serious Reportable Events==
The full list of "never events", serious reportable events, was developed by the National Quality Forum (NQF) in 2002, and refined in 2006. It includes the following:
<!--The following material is quoted from the source and should not be edited. This material falls under fair use-->
===Surgical Events===
*Surgery performed on the wrong body part
*Surgery performed on the wrong patient
*Wrong surgical procedure performed on a patient
*Unintended retention of a foreign object in a patient after surgery or other procedure
*Intraoperative or immediately postoperative death in an ASA Class I patient
 
===Product of Device Events===
*Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility
*Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended
*Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility
 
===Patient Protection Events===
*Infant discharged to the wrong person
*Patient death or serious disability associated with patient leaving the facility without permission
*Patient suicide, or attempted suicide, resulting in serious disability while being cared for in a healthcare facility
 
===Care Management Events===
*Patient death or serious disability associated with a medication error (e.g. errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)
*Patient death or serious disability associated with a hemolytic  reaction (abnormal breakdown of red blood cells) due to the administration of ABO/HLA – incompatible blood or blood products
*Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility
*Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
*Death or serious disability associated with failure to identify and treat hyperbilirubinemia (condition where there is a high amount of bilirubin in the blood) in newborns
*Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
*Patient death or serious disability due to spinal manipulative therapy
*Artificial insemination with the wrong donor sperm or wrong egg
 
===Environmental Events===
*Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility
*Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
*Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
*Patient death or serious disability associated with a fall while being cared for in a healthcare facility
*Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility
 
===Criminal Events===
*Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
*Abduction of a patient of any age
*Sexual assault on a patient within or on the grounds of a healthcare facility
*Death or significant injury of a patient or staff member resulting form a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility<ref>[http://www.qualityforum.org/projects/completed/sre/fact-sheet.asp Fact Sheet Serious Reportable Events]</ref>
 
==The physician's perspective==
Medical case reports review the strongly negative emotional impact of mistakes on the doctors who allegedly commit them.<ref name="pmid6690918">{{cite journal |author=Hilfiker D |title=Facing our mistakes |journal=N. Engl. J. Med. |volume=310 |issue=2 |pages=118-22 |year=1984 |pmid=6690918 |doi=}}</ref><ref name="pmid1506949">{{cite journal |author=Christensen JF, Levinson W, Dunn PM |title=The heart of darkness: the impact of perceived mistakes on physicians |journal=Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine |volume=7 |issue=4 |pages=424-31 |year=1992 |pmid=1506949 |doi=}}</ref><ref name="pmid10720336">{{cite journal |author=Wu AW |title=Medical error: the second victim. The doctor who makes the mistake needs help too |journal=BMJ |volume=320 |issue=7237 |pages=726-7 |year=2000 |pmid=10720336 |doi=}}</ref><ref name="Waterman">{{cite journal |author=Waterman AD, Garbutt J, Hazel E, Dunagan WC, Levinson W, Fraser VJ, Gallagher TH. |title=The Emotional Impact of Medical Errors on Practicing Physicians in the United States and Canada |journal=Joint Commission Journal on Quality and Patient Safety |volume=33 |issue= |pages=467-476 |year=2007 |pmid=6690918 |doi=|url=http://www.ingentaconnect.com/content/jcaho/jcjqs/2007/00000033/00000008/art00001}}</ref><ref name="pmid17960011">{{cite journal |author=Delbanco T, Bell SK |title=Guilty, afraid, and alone--struggling with medical error |journal=N. Engl. J. Med. |volume=357 |issue=17 |pages=1682–3 |year=2007 |pmid=17960011 |doi=10.1056/NEJMp078104}}</ref>
 
===Coping mechanisms===
Essays<ref name="isbn0-89815-197-X">{{cite book |author=Oscar London |chapter=Rule 13: When You Make a Mistake So Horrible It is to Die Over, Don't|title=Kill as few patients as possible: and fifty-six other essays on how to be the world's best doctor |publisher=Ten Speed Press |location=Berkeley, Calif |year=1987 |pages=23-24 |isbn=0-89815-197-X |oclc= |doi=}}</ref> and studies<ref name="pmid2393317">Quill TE, Williamson PR. Healthy approaches to physician stress. Arch Intern Med. 1990;150:1857-61. PMID 2393317 </ref><ref name="pmid8601210">{{cite journal |author=Newman MC |title=The emotional impact of mistakes on family physicians |journal=Archives of family medicine |volume=5 |issue=2 |pages=71-5 |year=1996 |pmid=8601210 |doi=}}</ref> have described physician coping mechanisms.
 
====Mistakes are not isolated events====
Some doctors recognize that adverse outcomes from errors usually do not happen because of an isolated errors and actually reflect system problems.<ref name="pmid2013929">{{cite journal |author=Wu AW, Folkman S, McPhee SJ, Lo B |title=Do house officers learn from their mistakes? |journal=JAMA |volume=265 |issue=16 |pages=2089-94 |year=1991 |pmid=2013929 |doi=}}</ref> There may be several breakdowns in processes to allow one adverse outcome. <ref name="pmid17015866">{{cite journal |author=Gandhi TK, Kachalia A, Thomas EJ, ''et al'' |title=Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims |journal=Ann. Intern. Med. |volume=145 |issue=7 |pages=488-96 |year=2006 |pmid=17015866 |doi=}}</ref> In addition, competing demands<ref name="pmid2725617">{{cite journal |author=Lurie N, Rank B, Parenti C, Woolley T, Snoke W |title=How do house officers spend their nights? A time study of internal medicine house staff on call |journal=N. Engl. J. Med. |volume=320 |issue=25 |pages=1673-7 |year=1989 |pmid=2725617 |doi=}}</ref><ref name="pmid1275366">{{cite journal |author=Lyle CB, Applegate WB, Citron DS, Williams OD |title=Practice habits in a group of eight internists |journal=Ann. Intern. Med. |volume=84 |issue=5 |pages=594-601 |year=1976 |pmid=1275366 |doi=}}</ref> on the provider's attention can reduce quality of care<ref name="pmid9593791"/><ref name="pmid18219539">{{cite journal |author=Bolen SD, Samuels TA, Yeh HC, ''et al'' |title=Failure to intensify antihypertensive treatment by primary care providers: a cohort study in adults with diabetes mellitus and hypertension |journal=J Gen Intern Med |volume=23 |issue=5 |pages=543–50 |year=2008 |month=May |pmid=18219539 |doi=10.1007/s11606-008-0507-2 |url=http://dx.doi.org/10.1007/s11606-008-0507-2 |issn=}}</ref>. However, placing too much blame on the system may not be constructive.<ref name="pmid2013929"/>
 
====Medicine in perspective====
Essayists imply that the potential to make mistakes is part of what makes being a physician rewarding and without this potential the rewards of medical practice would be less:
* "Everybody dies, you and all of your patients. All relationships end. Would you want it any other way?...Don't take it personally"<ref name="isbn1-56053-603-9">{{cite book |author=Thomas Laurence, |chapter=What Do You Want?|title=Extreme Clinic -- An Outpatient Doctor's Guide to the Perfect 7 Minute Visit |publisher=Hanley & Belfus |location=Philadelphia |year=2004 |pages=120 |isbn=1-56053-603-9 |oclc= |doi=}}</ref>
* "... if I left medicine, I would mourn its loss as I've mourned the passage of my poetry. On a daily basis, it is both a privilege and a joy to have the trust of patients and their families and the camaraderie of peers.  There is no challenge to make your blood race like that of a difficult case, no mind game as rigorous as the challenging differential diagnosis, and though the stakes are high, so are the rewards."<ref name="pmid16418416">{{cite journal |author=Seder D |title=Of poems and patients |journal=Ann. Intern. Med. |volume=144 |issue=2 |pages=142 |year=2006 |pmid=16418416 |doi=|url=http://www.annals.org/cgi/content/full/144/2/142}}</ref>
 
====Disclosing mistakes====
[[Forgiveness]], which is a part of many religions, may be important in coping with medical mistakes.<ref name="pmid15681676">{{cite journal |author=Berlinger N, Wu A |title=Subtracting insult from injury: addressing cultural expectations in the disclosure of medical error |journal=J Med Ethics |volume=31 |issue=2 |pages=106-8 |year=2005 |pmid=15681676}}</ref>
 
=====To oneself=====
Inability to forgive oneself may create a cycle of distress and increased likelihood of a future error.<ref name="pmid16954486">{{cite journal |author=West CP, Huschka MM, Novotny PJ, ''et al'' |title=Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study |journal=JAMA |volume=296 |issue=9 |pages=1071-8 |year=2006 |pmid=16954486 |doi=10.1001/jama.296.9.1071}}</ref>
 
However, "...those who coped by accepting responsibility were more likely to make constructive changes in practice, but to experience more emotional distress."<ref name="pmid8279153">{{cite journal |author=Wu AW, Folkman S, McPhee SJ, Lo B |title=How house officers cope with their mistakes |journal=West. J. Med. |volume=159 |issue=5 |pages=565-9 |year=1993 |pmid=8279153 |doi=}}</ref> It may be helpful to consider the much larger number of patients who are not exposed to mistakes and are helped by medical care.<ref name="pmid16418416"/>
 
=====To patients=====
Patients are reported to want "information about what happened, why the error happened, how the error's consequences will be mitigated, and how recurrences will be prevented."<ref name="pmid12597752">{{cite journal |author=Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W |title=Patients' and physicians' attitudes regarding the disclosure of medical errors |journal=JAMA |volume=289 |issue=8 |pages=1001-7 |year=2003 |pmid=12597752 |doi=}}</ref> Detailed suggestions on how to disclose are available.<ref name="pmid9436897">{{cite journal |author=Wu AW, Cavanaugh TA, McPhee SJ, Lo B, Micco GP |title=To tell the truth: ethical and practical issues in disclosing medical mistakes to patients |journal=Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine |volume=12 |issue=12 |pages=770-5 |year=1997 |pmid=9436897 |doi=10.1046/j.1525-1497.1997.07163.x|url=http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=9436897}}</ref>
 
The American Medical Association's Council on Ethical and Judicial Affairs states in its ethics code:
:"Situations occasionally occur in which a patient suffers significant medical complications that may have resulted from the physician's mistake or judgment. In these situations, the physician is ethically required to inform the patient of all facts necessary to ensure understanding of what has occurred. Concern regarding legal liability which might result following truthful disclosure should not affect the physician's honesty with a patient."
 
From the American  College of Physicians Ethics Manual<ref name="pmid15809467">{{cite journal |author=Snyder L, Leffler C |title=Ethics manual: fifth edition |journal=Ann Intern Med |volume=142 |issue=7 |pages=560-82 |year=2005 |pmid=15809467}}</ref>:
:“In addition, physicians should disclose to patients information about procedural or judgment errors made in the course of care if such information is material to the patient's well-being. Errors do not necessarily constitute improper, negligent, or unethical behavior, but failure to disclose them may.”
 
However, "there appears to be a gap between physicians' attitudes and practices regarding error disclosure. Willingness to disclose errors was associated with higher training level and a variety of patient-centered attitudes, and it was not lessened by previous exposure to malpractice litigation".<ref name="pmid17473944">{{cite journal |author=Kaldjian LC, Jones EW, Wu BJ, Forman-Hoffman VL, Levi BH, Rosenthal GE |title=Disclosing medical errors to patients: attitudes and practices of physicians and trainees |journal=Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine |volume=22 |issue=7 |pages=988-96 |year=2007 |pmid=17473944 |doi=10.1007/s11606-007-0227-z}}</ref> Hospital administrators may share these concerns.<ref name="pmid15769969">{{cite journal |author=Weissman JS, Annas CL, Epstein AM, ''et al'' |title=Error reporting and disclosure systems: views from hospital leaders |journal=JAMA |volume=293 |issue=11 |pages=1359-66 |year=2005 |pmid=15769969 |doi=10.1001/jama.293.11.1359}}</ref>
 
Consequently, in the [[United States of America]], many states have enacted laws excluding expressions of sympathy after accidents as proof of liability; however, "excluding from admissibility in court proceedings apologetic expressions of sympathy but not fault-admitting apologies after accidents"<ref name="sorryworks.net">{{cite web |url=http://www.sorryworks.net/ |title=SorryWorks.net |accessdate=2007-08-16 |format= |work=}}</ref>
 
Disclosure may actually reduce malpractice payments.<ref name="pmid10610651">{{cite journal |author=Wu AW |title=Handling hospital errors: is disclosure the best defense? |journal=Ann. Intern. Med. |volume=131 |issue=12 |pages=970-2 |year=1999 |pmid=10610651 |doi=}}</ref><ref name="pmidWSJ">{{cite news |first= |last= |authorlink= |author=Zimmerman R |coauthors= |title=Doctors' New Tool To Fight Lawsuits: Saying 'I'm Sorry' |url=http://online.wsj.com/article/0,,SB108482777884713711,00.html |format= |work= |publisher=Dow Jones & Company, Inc |id= |pages= |page= |date=May 18,2004 |accessdate=2007-08-16 |language= |quote= |archiveurl= |archivedate= }}</ref>
 
=====To non-physicians=====
In a study of physicians who reported having made a mistake, disclosing to non-physicians sources of support may reduce stress more than disclosing to physician colleagues<ref name="pmid8601210"/>. This may be due to the physicians in the same study, when presented with a hypothetical scenario of a mistake made by another colleague, only 32% physicians would have unconditionally offered support. It is possible that greater benefit occurs when spouses are physicians<ref name="pmid10068390">{{cite journal |author=Sobecks NW, Justice AC, Hinze S, ''et al'' |title=When doctors marry doctors: a survey exploring the professional and family lives of young physicians |journal=Ann. Intern. Med. |volume=130 |issue=4 Pt 1 |pages=312-9 |year=1999 |pmid=10068390 |doi=}}</ref>.
 
=====To other physicians=====
Discussing mistakes with other doctors is beneficial.<ref name="pmid2013929">{{cite journal |author=Wu AW, Folkman S, McPhee SJ, Lo B |title=Do house officers learn from their mistakes? |journal=JAMA |volume=265 |issue=16 |pages=2089-94 |year=1991 |pmid=2013929 |doi=}}</ref> However, doctors may be less forgiving of each other.<ref name="pmid10068390"/> The reason is not clear, but one essayist has admonished, "Don't Take Too Much Joy in the Mistakes of Other Doctors."<ref name="isbn0-89815-197-X-b">{{cite book |author=Oscar London |chapter=Rule 35: Don't Take Too Much Joy in the Mistakes of Other Doctors|title=Kill as few patients as possible: and fifty-six other essays on how to be the world's best doctor |publisher=Ten Speed Press |location=Berkeley, Calif |year=1987 |pages= |isbn=0-89815-197-X |oclc= |doi=}}</ref>
 
=====Disclosure to the physician's institution=====
Disclosure of errors, especially 'near misses' may be able to reduce subsequent errors in institutions that are capable of reviewing near misses.<ref name="pmid10720361">{{cite journal |author=Barach P, Small SD |title=Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems |journal=BMJ |volume=320 |issue=7237 |pages=759-63 |year=2000 |pmid=10720361 |doi=}}</ref> However, doctors report that institutions may not be supportive of the doctor.<ref name="pmid2013929"/>
 
==See also==
* [[Medical malpractice]]
* [[Health care quality assurance]]


==References==
==References==
*[http://www.infectioncontroltoday.com/hotnews/6ch127223175711.html "IHI Launches National Initiative to Reduce Medical Harm in U.S. Hospitals, Builds on 100,000 Lives Campaign"]
<small>
*The [[Wikipedia]] article "[http://en.wikipedia.org/wiki/Medical_error Medical error]" was consulted during the writing of this article and certain materials referenced in it were used. <!--or will be, taking another break, probably until tomorrow-->
<references>
 
</references>
</small>  


==Further Reading==
Atul Gawande. Complications. A Surgeon's Notes on an Imperfect Science. ISBN 0-312-42170-2


[[Category:CZ Live]][[Category:Health Sciences Workgroup|Medicine]]
[[Category:Suggestion Bot Tag]]

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Medical errors are mistakes that are made in a medical setting. Errors are made by every type of health care worker, and in every hospital and health care facility. In 2001, the U.S. Institute of Medicine estimated that, every year, 44,000–98,000 deaths in the USA were related to medical errors. [1]

Errors are not limited to medical workers and may include any decision maker involved in medical care, including the patient themselves. For example, reimbursements by medical insurance may be poorly structured resulting in less than optimal outcomes.[2]

When an error occurs, the key question becomes, will it be recognized and corrected? Errors that eventually result in injury are typically compounded by subsequent errors of not recognizing that an error has occurred, and not taking remedial action.

Epidemiology/frequency

Errors may occur among hospitalized patients, ambulatory patients, or patients after discharge from the hospital.[3]

The frequency of errors is higher when physicians and patients are asked about their experience with errors among their families.[4]

The frequency of meaningful medical error is debated.[5]

Most patients in intensive care experience at least one error.[6]

Reporting requirements

In the United States reporting medical errors in hospitals is a condition of payment by Medicare.[7] An investigation by the Office of Inspector General, Department of Health and Human Services released January 6, 2012 found that most errors are not reported and even in the case of errors that are reported and investigated changes are seldom made which would prevent them in the future. The investigation revealed that there was often lack of knowledge regarding which events were reportable and recommended that lists of reportable events be developed. [8]

Classification

Errors can be classified into "no fault," "system-related", and "cognitive".[9]

No fault

Examples including overlooking a disease that in a patient with manifestations so atypical that most doctors would not be expected to recognize the underlying disease.

System-related

Examples of system errors include "problems with policies and procedures, inefficient processes, teamwork, and communication."[9] Errors may happen during transfer of care.[10] In medical training, breakdowns in teamwork (including supervision) are a cause[11][12], especially at the beginning of the academic year[13][14].

Interruptions have a complicated affect on error and cognition.[15]

Unclear instructions to health personnel

Unclear prose, whether in institutional instructions[16] or reports[17][18], may contribute to errors.

Ill-defined clinical flow processes

The results of abnormal diagnostic tests may not acted upon.[19][20]

Work load

Examining errors in administration of parenteral medications in intensive care, a study found:[21]

  • 74 errors per 100 patient-days
  • Independent risk factors were:
    • Patient complexity as measured by
      • number of organ failures
      • number of parenteral administrations
    • Work load as measured by
      • Larger intensive care unit
      • Increased ratio of patient turnover to the size of the unit
      • Number of patients per nurse
      • Occupancy rate of the unit

Workload may also be associated with adverse outcomes in emergency rooms.[22]

On the other hand, insufficient volume of care is associated with reduced quality of care.[23]

Inadequate staffing

Many studies show that adverse events are associated with low staffing.[24][25][26]

Weekends and off hours

Inadequate provision of medical care for patients admitted on weekends may increase adverse outcomes in most[27][28][29][30][31][32] but not all[33] studies. The same may be true for in-hospital cardiac arrest.[32] "The weekend effect was larger in major teaching hospitals compared with nonteaching hospitals."[30]

The reduced quality of care during off hours may improve as a hospital has more experience in quality improvement.[34]

Failure to rescue

Hospitals have similar incidence of surgical complications, yet varying incidence of nosocomial death. This suggests that some hospitals have a "failure to rescue" patients from complications.[35]

Hospital discharge

For more information, see: Patient discharge.


Cognitive

Voytovich has suggested that diagnostic error due to cognitive errors can be further classified into omission of finding, premature closure, inadequate synthesis, and wrong formulation.[36] Similarly, Graber has classified cognitive error into faulty knowledge, faulty data gathering, and faulty synthesis (usually premature closure).[9] An additional classification has been proposed by Kassirer.[37] In medical trainees, cognitive errors are an important cause or medical error.[11] The many cognitive biases that can lead to cognitive error have been inventoried.[38][39]

Omission of finding

An example is recording a finding during data collection, but not including the finding on the problem list.[36]

Faulty data gathering

An example of faulty data gathering is and incomplete physical examination or not ordering needed tests.[9]

Premature closure

Premature closure is the most common cognitive error.[9][36]

Wrong formulation

Examples of wrong formulation or flawed reasoning are making a diagnosis that is contradicted by clinical findings.

Inadequate knowledge

Inadequate knowledge can be a factor[40], but is uncommon as an isolated problem in studies of causes of medical errors.[9] However, inadequate knowledge was found to be a more common problem in study of appropriateness of care among patients without identified medical errors.[41] It is unclear how often each of the types of cognitive errors such as an incomplete evaluation, omission of a finding, wrong formulation, are partly due to inadequate knowledge of diseases.

System-related cognitive deficits

At the interface between system-related errors and cognitive errors, one finds the errors that are learnt in the course of the formative years, in medical schools.

Needless to say, doctors are expected to have a very high degree of moral development: the profession requires an ability to make choices that will impact on the quality of life of innumerable patients, and to act appropriately and diligently when faced with life-or-death situations. Doctors are expected to master an enormous amount of knowledge, and to advance beyond when faced with the grey areas of clinical practice.

It is recognized that higher education has a favourable impact on moral development: university students tend to reason more in societal and principled terms when faced with ethical issues, and less in terms of self-interest or peer approval, the more they advance in their university curriculum. The medical curriculum is a notable exception to this rule.

It is now recognized that medical education, as it is today, hinders moral development.[42][43][44]The reason why medical education forms doctors that will be less able to take ethical decisions than other professionals with comparable levels of education is still not known with certainty, although the so-called "hidden curriculum"[45] appears to be a likely culprit.[46]

Patient related

Patients who have more medical problems[47] and more complaints[48] may have reduced quality of care due to competing demands on physician time.

Malpractice

For more information, see: Medical malpractice.

If an error involves negligence and results in damage, as those terms are legally defined, it may be treated as medical malpractice and result in substantial liability. The possibility of legal liability can be a barrier to free discussion and disclosure of medical error, hampering efforts to reduce error. Thus, provisions for confidential reporting of errors can be useful.

Prevention

Lessons from aviation

Plane crashes can be dramatic events, causing considerable loss of life and attracting wide publicity damaging to the reputation of the airlines involved, and weakening passenger confidence in air travel. Accordingly, all plane crashes and related serious incidents ("near misses") are exhaustively investigated in an effort to establish their precise causes. By comparison, most medical errors do not have the same wide impact, thus they seldom receive such intense scrutiny and analysis. [49]

An adapted version of a "pilot's checklist" (designed to ensure that safety procedures are rigorously followed when preparing for take-off and landing) has been tested for usefulness in preparation for performing Cesarean delivery under general anesthesia. [50]

Another aviation safety method, with potential healthcare benefit, is crew resource management (CRM), also called cockpit resource management. While the captain of an aircraft is the ultimate authority, CRM helps ensure that all crew members are proactive in sharing safety-related information. [51] Some of CRM principles include peer monitoring, acceptance that team members do make errors, and that each team member has responsibility both for the patient and for situational awareness. The method cannot be transferred directly to medicine, but has potential to be modified to medicine.

Some of the differences include that cockpit crew are usually all certified pilots with differing levels of experience in the same basic skill set, while healthcare teams involve people not only with different levels of experience, but different skills and lack of skills. A surgeon may not have the physiologic intuition of an anesthesiologist, but the surgeon is the authority. An experienced surgical nurse may see a young surgeon about to make an error, but a concept of nurse vs. physician roles may reduce the chance of a warning being issued, or perhaps being accepted.

Aviators also have one motivator that is far less common than in medicine: shared fate. While a break in barrier methods may infect a healthcare team member, the implications are not as drastic as the failure of a copilot to assert the aircraft did not have adequate takeoff speed, which should have caused the takeoff to be aborted, rather than Air Florida 93 crashing into the 14th Street Bridge in Washington DC.

Hospital design

See also: electronic medical record, electronic health record, clinical decision support system, and medical order entry system.

Patients placed in isolation rooms for infection control "experience more preventable adverse events, express greater dissatisfaction with their treatment, and have less documented care."[52]

Bar coding medication administration may reduce errors.[53]

Personnel factors

Sleep deprivation

Sleep deprivation may contribute to errors.[54]

Reduction of duty hours

See also Medical education

A survey of 200 residents who trained both before and after duty hours reform reported improved quality of life. However, "Residents reported that whereas fatigue-related errors decreased slightly, errors related to reduced continuity of care significantly increased." [55] Resident believe excessive work hours is a common cause of medical error.[56][57][58]

Restricting duty hours may[59][60][61] or may not[62] improve performance. However, restrictions may be costly.[63]

Oversight of professional conduct

It is not clear that the oversight of professional conduct prevents errors.

Organizations promoting error reduction

Institute for Healthcare Improvement

The Institute for Healthcare Improvement (IHI) defines medical harm as "unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment) that requires additional monitoring, treatment or hospitalization, or results in death."

100,000 Lives Campaign

In 2004, the IHI initiated the 100,000 Lives Campaign.[64][65] That campaign, participated in by 3,200 hospitals, is estimated to have reduced deaths of patients in hospitals by 122,000 in 18 months. The campaign focused on six "interventions", three focused on common hospital-acquired (nosocomial infections), which had been identified as likely to reduce medical error:

  1. "Deploy Rapid Response Teams…at the first sign of patient decline". Rapid Response Teams (RRSs) are teams of critical care experts. Use of Rapid Response Teams has increased dramatically in U.S. Hospitals, from near zero in 2003 to 1500 in 2006. [66] RRSs have been helpful in some[67], but not all studies.[68][69]
  2. "Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack."
  3. "Prevent Adverse Drug Events (ADEs)…by implementing medication reconciliation."[70][71]
  4. "Prevent Central Line Infections…by implementing a series of interdependent, scientifically grounded steps called the "Central Line Bundle"."
  5. "Prevent Surgical Site Infections…by reliably delivering the correct perioperative antibiotics at the proper time." Significant reduction may be achieved by procedures as simple as proper hand washing, use of clippers rather than razors to shave the site of surgery, or prompt administration of antibiotics following surgery.[66][72]
  6. "Prevent Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps including the 'Ventilator Bundle'."
5 Million Lives Campaign

IHI's second campaign, the 5 Million Lives Campaign, [73] aims to eliminate five million incidents of medical harm during a 24-month period, ending Dec. 9, 2008. The campaign challenges 4,000 hospitals to adopt at least one of twelve interventions: the six original interventions and the following six more: [74] [75]

  1. "Prevent Harm from High-Alert Medications... starting with a focus on anticoagulants, sedatives, narcotics, and insulin."
  2. "Reduce Surgical Complications... by reliably implementing all of the changes in care recommended by SCIP, the Surgical Care Improvement Project (http://www.medqic.org/scip)."
  3. "Prevent Pressure Ulcers... by reliably using science-based guidelines for their prevention."
  4. "Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) infection…by reliably implementing scientifically proven infection control practices."
  5. "Deliver Reliable, Evidence-Based Care for Congestive Heart Failure... to avoid readmissions."
  6. "Get Boards on Board … by defining and spreading the best-known leveraged processes for hospital Boards of Directors, so that they can become far more effective in accelerating organizational progress toward safe care."

Agency for Healthcare Research Quality

The American Agency for Healthcare Research and Quality has established 11 priority areas:[76]

  1. Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk.
  2. Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality.
  3. Use of maximum sterile barriers while placing central intravenous catheters to prevent infections.
  4. Appropriate use of antibiotic prophylaxis in surgical patients to prevent perioperative infections.
  5. Asking that patients recall and restate what they have been told during the informed consent process.
  6. Continuous aspiration of subglottic secretions (CASS) to prevent ventilator-associated pneumonia.
  7. Use of pressure relieving bedding materials to prevent pressure ulcers.
  8. Use of real-time ultrasound guidance during central line insertion to prevent complications.
  9. Patient self-management for warfarin (CoumadinTM) to achieve appropriate outpatient anticoagulation and prevent complications.
  10. Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients.
  11. Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections.

Joint Commission

The Joint Commission promotes a number of goals that are listed at http://www.jcrinc.com/National-Patient-Safety-Goals/.

United States Surgeon General

The United States of America Surgeon General has announced calls to action to improve medical care in the following areas:

  • Prevent Deep Vein Thrombosis and Pulmonary Embolism
  • Prevent and Reduce Underage Drinking
  • The Surgeon General’s Call to Action to Improve the Health and Wellness of Persons with Disabilities
  • National Call To Action To Promote Oral Health
  • Prevent and Decrease Overweight and Obesity
  • Promote Sexual Health and Responsible Sexual Behavior
  • Prevent Suicide

The Patient Advocate

Reduction of medical error can be effected on the patient side as well as on the side of the care giver, but only with vigilance on the part of the patient him or herself, or on the part of the patient's advocate.

Payment

Generally medical treatment to correct medical error has been considered billable, but effective October 1, 2008 Medicare will discontinue paying hospitals for treatment resulting from 10 common medical errors. Other insurance carriers are expected to follow suit.[77][78][79] In addition to 7 other conditions, the errors which not will be paid for include three "never events": objects left in the body during surgery, air embolisms and blood incompatibility.[80]

Serious Reportable Events

The full list of "never events", serious reportable events, was developed by the National Quality Forum (NQF) in 2002, and refined in 2006. It includes the following:

Surgical Events

  • Surgery performed on the wrong body part
  • Surgery performed on the wrong patient
  • Wrong surgical procedure performed on a patient
  • Unintended retention of a foreign object in a patient after surgery or other procedure
  • Intraoperative or immediately postoperative death in an ASA Class I patient

Product of Device Events

  • Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility
  • Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended
  • Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility

Patient Protection Events

  • Infant discharged to the wrong person
  • Patient death or serious disability associated with patient leaving the facility without permission
  • Patient suicide, or attempted suicide, resulting in serious disability while being cared for in a healthcare facility

Care Management Events

  • Patient death or serious disability associated with a medication error (e.g. errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)
  • Patient death or serious disability associated with a hemolytic reaction (abnormal breakdown of red blood cells) due to the administration of ABO/HLA – incompatible blood or blood products
  • Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility
  • Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
  • Death or serious disability associated with failure to identify and treat hyperbilirubinemia (condition where there is a high amount of bilirubin in the blood) in newborns
  • Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
  • Patient death or serious disability due to spinal manipulative therapy
  • Artificial insemination with the wrong donor sperm or wrong egg

Environmental Events

  • Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility
  • Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
  • Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
  • Patient death or serious disability associated with a fall while being cared for in a healthcare facility
  • Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility

Criminal Events

  • Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
  • Abduction of a patient of any age
  • Sexual assault on a patient within or on the grounds of a healthcare facility
  • Death or significant injury of a patient or staff member resulting form a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility[81]

The physician's perspective

Medical case reports review the strongly negative emotional impact of mistakes on the doctors who allegedly commit them.[82][83][84][85][86]

Coping mechanisms

Essays[87] and studies[88][89] have described physician coping mechanisms.

Mistakes are not isolated events

Some doctors recognize that adverse outcomes from errors usually do not happen because of an isolated errors and actually reflect system problems.[90] There may be several breakdowns in processes to allow one adverse outcome. [91] In addition, competing demands[92][93] on the provider's attention can reduce quality of care[47][94]. However, placing too much blame on the system may not be constructive.[90]

Medicine in perspective

Essayists imply that the potential to make mistakes is part of what makes being a physician rewarding and without this potential the rewards of medical practice would be less:

  • "Everybody dies, you and all of your patients. All relationships end. Would you want it any other way?...Don't take it personally"[95]
  • "... if I left medicine, I would mourn its loss as I've mourned the passage of my poetry. On a daily basis, it is both a privilege and a joy to have the trust of patients and their families and the camaraderie of peers. There is no challenge to make your blood race like that of a difficult case, no mind game as rigorous as the challenging differential diagnosis, and though the stakes are high, so are the rewards."[96]

Disclosing mistakes

Forgiveness, which is a part of many religions, may be important in coping with medical mistakes.[97]

To oneself

Inability to forgive oneself may create a cycle of distress and increased likelihood of a future error.[98]

However, "...those who coped by accepting responsibility were more likely to make constructive changes in practice, but to experience more emotional distress."[99] It may be helpful to consider the much larger number of patients who are not exposed to mistakes and are helped by medical care.[96]

To patients

Patients are reported to want "information about what happened, why the error happened, how the error's consequences will be mitigated, and how recurrences will be prevented."[100] Detailed suggestions on how to disclose are available.[101]

The American Medical Association's Council on Ethical and Judicial Affairs states in its ethics code:

"Situations occasionally occur in which a patient suffers significant medical complications that may have resulted from the physician's mistake or judgment. In these situations, the physician is ethically required to inform the patient of all facts necessary to ensure understanding of what has occurred. Concern regarding legal liability which might result following truthful disclosure should not affect the physician's honesty with a patient."

From the American College of Physicians Ethics Manual[102]:

“In addition, physicians should disclose to patients information about procedural or judgment errors made in the course of care if such information is material to the patient's well-being. Errors do not necessarily constitute improper, negligent, or unethical behavior, but failure to disclose them may.”

However, "there appears to be a gap between physicians' attitudes and practices regarding error disclosure. Willingness to disclose errors was associated with higher training level and a variety of patient-centered attitudes, and it was not lessened by previous exposure to malpractice litigation".[103] Hospital administrators may share these concerns.[104]

Consequently, in the United States of America, many states have enacted laws excluding expressions of sympathy after accidents as proof of liability; however, "excluding from admissibility in court proceedings apologetic expressions of sympathy but not fault-admitting apologies after accidents"[105]

Disclosure may actually reduce malpractice payments.[106][107]

To non-physicians

In a study of physicians who reported having made a mistake, disclosing to non-physicians sources of support may reduce stress more than disclosing to physician colleagues[89]. This may be due to the physicians in the same study, when presented with a hypothetical scenario of a mistake made by another colleague, only 32% physicians would have unconditionally offered support. It is possible that greater benefit occurs when spouses are physicians[108].

To other physicians

Discussing mistakes with other doctors is beneficial.[90] However, doctors may be less forgiving of each other.[108] The reason is not clear, but one essayist has admonished, "Don't Take Too Much Joy in the Mistakes of Other Doctors."[109]

Disclosure to the physician's institution

Disclosure of errors, especially 'near misses' may be able to reduce subsequent errors in institutions that are capable of reviewing near misses.[110] However, doctors report that institutions may not be supportive of the doctor.[90]

See also

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