Errors in medicine

doi:10.1016/j.cca.2009.03.020

Clinica Chimica Acta

Volume 404, Issue 1, 6 June 2009, Pages 2-5

https://doi.org/10.1016/j.cca.2009.03.020 Get rights and content

Abstract

Modern awareness of the problem of medical injury – complications of treatment – can be fairly dated to the publication in 1991 of the results of the Harvard Medical Practice Study, but it was not until the publication of the 2000 Institute of Medicine (IOM) report, To Err is Human that patient safety really came to medical and public attention. Medical injury is a serious problem, affecting, as multiple studies have now shown, approximately 10% of hospitalized patients, and causing hundreds of thousands of preventable deaths each year. The organizing principle is that the cause is not bad people, it is bad systems. This concept is transforming; it replaces the previous exclusive focus on individual error with a focus on defective systems. Although the major focus on patient safety has been on implementing safe practices, it has become increasingly apparent that achieving a high level of safety in our health care organizations requires much more: several streams have emerged. One of these is the recognition of the importance of engaging patients more fully in their care. Another is the need for transparency. In the current health care organizational environment in most hospitals, at least six major changes are required to begin the journey to a culture of safety: 1. We need to move from looking at errors as individual failures to realizing they are caused by system failures; 2. We must move from a punitive environment to a just culture; 3. We move from secrecy to transparency; 4. Care changes from being provider (doctors) centered to being patient-centered; 5. We move our models of care from reliance on independent, individual performance excellence to interdependent, collaborative, interprofessional teamwork; 6. Accountability is universal and reciprocal, not top-down.

Section snippets

History

Modern awareness of the problem of medical injury – complications of treatment – can be fairly dated to the publication in 1991 of the results of the Harvard Medical Practice Study [1], [2]. This review of 30,000 medical records of patients hospitalized in New York state showed that 4% of patients had complications of their treatment, which we call adverse events. Even more shocking was the finding that two-thirds of these iatrogenic injuries were due to mistakes and therefore were preventable.

Achieving safe health care

Although the major focus has been on implementing safe practices, it has become increasingly apparent that achieving a high level of safety in our health care organizations requires much more. Several streams have emerged. One of these is the recognition of the importance of engaging patients more fully in their care. Another is the need for transparency. Safety experts and patient advocates agree that patients have a right to know all about their care, especially when things go wrong. Full

What have we learned?

From this relatively short experience, we have already learned a great deal. The most important lesson is that systems theory works. Errors and injuries can, in fact, be prevented by redesigning systems to make it difficult, and sometimes impossible, for caregivers to make mistakes. A classic example is the elimination of accidental (fatal) intravenous injections of concentrated potassium chloride by removing the medication from the nursing units and requiring it to be added to intravenous

A culture of safety

What is a culture of safety? Various authors have defined it in different ways. James Reason emphasizes that a safe culture includes three characteristics. First and foremost it must be a just culture: people are not punished for making errors, but deliberate violations and misconduct are not tolerated. Second, it must be a reporting culture: the environment must be safe for people to talk about errors and report them. Only in that way can we discover our problems and fix them. Finally, it must

Making the changes: the importance of teamwork

Return to the problem of hand hygiene. Most hospitals have a policy requiring everyone, doctors, nurses, technicians, assistants, to disinfect their hands before and after touching a patient. But compliance in most hospitals is dismal. Why? The reason is that we do not work in teams. Compliance is, appropriately, an individual responsibility. But it is more likely to happen when caregivers work together in teams. And most doctors and other caregivers do not know much about working in teams.

The safety challenge in laboratory medicine

In terms of quality control, and error rates specifically, laboratory medicine has a far better record than most other fields in health care. In the analytic phase, some studies indicate that the average error rate is as low as 0.002%. This is functioning at the 5 sigma level. For comparison, the rates of infections and medication errors are closer to 3 sigma, i.e., defect rates > 3000 times those in the laboratory! (Fig. 1).

When the entire process of selecting, ordering, obtaining specimens,

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View full text

Errors in medicine

Abstract

Section snippets

History

Achieving safe health care

What have we learned?

A culture of safety

Making the changes: the importance of teamwork

The safety challenge in laboratory medicine

Organ Dyn

Jt Comm J Qual Patient Saf

Incidence of adverse events and negligence in hospitalized patients: results from the Harvard Medical Practice Study I

NEJM

The nature of adverse events in hospitalized patients: results from the Harvard Medical Practice Study II

N Engl J Med

Systems analysis of adverse drug events

JAMA

The quality in Australian health care study

Med J Aust

Adverse events in British hospitals: preliminary retrospective record review

Br Med J

The 100,000 Lives Campaign — setting a goal and a deadline for improving health care quality

JAMA

When things go wrong

Problem doctors: is there a system-level solution?

Ann Intern Med

ABMS. ABMS Maintenance of Certification: MOC competencies and criteria