Preventing Medical Errors in Hospitals

Medical error can be understood as an unintended act either of commission or omission, within the context of healthcare. Errors can occur at either the individual- or systems-level and play a complex role. Although many errors may be without consequence, medical errors can cause patient harm and lead to or accelerate death.

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What are medical errors and what is the scale of the problem?

Medical errors cause a significant burden to patients and healthcare providers globally, leading to avoidable suffering, increased illness and increased costs of care. In the United States, medical errors are thought to be the third most common cause of death after cancer and heart disease.

Understanding the scope of the problem is challenging, primarily because reports tend to capture only the most serious of errors; those which cause disability or death. Two benchmark studies conducted in the 1980s and 1990s reviewed the medical records of over 30,000 patients admitted to more than 50 hospitals in the US and 14,000 records in Australia respectively.

The US found that serious injuries arising from medical management had occurred in 3.7% of patients with 69% of cases due to error. The Australian study found that adverse events leading to permanent disability occurred in 13.7% of admissions, and 4.9% in death, with 51% of adverse events being due to error.

Although wide in scope, it has been repeatedly acknowledged that these studies likely under-report the error rate as in many cases errors do not ultimately cause serious injury.

What are the different types of medical errors?

Medical errors can be classified into four groups:

Diagnostic: Includes a failure to employ relevant tests, or using outdated tests, delays or mistakes in diagnosis, and the failure to act on test results appropriately.

Treatment: Includes error when performing tests, treatments or procedures, error in drug dose or administration and avoidable delay in providing treatment.

Preventative: Includes inadequate monitoring or follow-up of treatment, or failure to provide prophylactic (preventative) treatment.

Other: Includes equipment failure, errors in communication or any other system failure.

How can medical errors be prevented?

Identify the most at-risk areas

One strategy for minimizing injury from medical error is to identify the areas where risk is greatest. Surgery is one such area: a complex and dynamic specialty that relies on technical skills, teamwork and complex equipment to treat a high volume of patients.

The US and Australian studies both found that surgical injuries accounted for almost half of all reported adverse events. Developing and implementing robust surgical protocols, conducting skills assessments of surgeons and support staff and providing error training whereby errors are made in a controlled environment may mitigate against some of the risks.

Understanding which patients are most at risk of serious injury from errors is important. Older patients and more complex patients are more likely to incur serious disability or death from medical errors than young and relatively healthy patients. Resources such as safety training, checklists and feedback systems can be then be directed towards areas that treat the most vulnerable.

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Implementing evidence-based interventions

Medical care is not delivered by individual clinicians; it is provided by teams of staff working across all levels of healthcare. Researchers have identified six factors of good teamwork: communication, coordination, conflict resolution, cooperation, shared views of the patient and strong leadership. These factors are incorporated into training protocols that are used in hospitals.

One example is TeamSTEPPS, which is used in approximately 70 percent of U.S. hospitals. It includes a curriculum targeting competencies in team structure, situation monitoring, communication, leadership and providing support. One recent meta-analysis found that team-level training interventions such as TeamSTEPPS reduced medical errors by 20%.

Another evidence-based strategy is the development of good protocols for handoffs. Handoffs occur when the care of a patient is transferred from one care provider to another and are so prone to error that many residency programs now mandate handoff training.

Training emphasizes the importance of providing information clearly and face-to-face. The impact of handoff training was explored in two large prospective studies, which both found reductions in errors and poor patient outcomes.

Technology

Electronic patient records have become the norm across many healthcare systems and are designed to help reduce medical errors by creating one easily shareable record that can be accessed across healthcare providers, mitigating the risk of overlooking issues such as medication allergies or concomitant medications.

However, such systems are still at risk of poor or incomplete data entry and as such, several programs have developed systems of electronic record monitoring to track anonymized information about medical errors and ‘near-misses’.

The theory behind such systems is that whilst human error is unavoidable, creating systems that accurately measure the frequency, visibility and impact of medical errors can provide some mitigation.

Some studies have shown that such systems can reduce errors by providing generalizable findings about the commonest types of error, their causes and potential solutions. Strategies include increasing the visibility of errors to increase the opportunity to intervene and highlighting which areas are most vulnerable to human limitations.

References

American Psychological Association. Preventing Medical Errors. [online] Available at: <https://www.apa.org/monitor/2016/09/preventing-errors> [Accessed December 2020].

Ghaferi AA, Birkmeyer JD, Dimick JB. Complications, failure to rescue, and mortality with major inpatient surgery in medicare patients. Ann Surg. 2009 Dec;250(6):1029-34. doi: 10.1097/sla.0b013e3181bef697. PMID: 19953723.

Grzybicki DM, Turcsanyi B, Becich MJ, Gupta D, Gilbertson JR, Raab SS. Database construction for improving patient safety by examining pathology errors. Am J Clin Pathol. 2005 Oct;124(4):500-9. doi: 10.1309/XN25JG7K0JFJB10C. PMID: 16146808.

Makary Martin A, Daniel Michael. Medical error—the third leading cause of death in the US BMJ 2016; 353 :i2139

Weingart, S. N., McL Wilson R, Gibberd, R. W., & Harrison, B. (2000). Epidemiology of medical error. The Western journal of medicine, 172(6), 390–393. https://doi.org/10.1136/ewjm.172.6.390