Diane C. Pinakiewicz, MBA
Infant twins are accidentally given an adult dose of heparin — a blood thinner — that is 10,000 times greater than the dose they should have received.
An eye surgeon operates on a child’s left eye even though she herself marked the right eye as the diseased eye prior to surgery.
A young man who is admitted to the intensive care unit with pneumonia quickly acquires several more infections — and he never makes it home.
By now, if you’ve ever read a newspaper or watched the nightly news, you’ve probably heard a story or two similar to these. Like many of us, you may have shaken your head and asked yourself, “How could that have happened?”
When medical errors occur, hospitals and healthcare providers ask themselves that very question. Rarely are such cases the result of malicious intent or careless oversight. Usually, medical errors happen as a result of a series of small breakdowns that occur in the complex chain of activity that makes up a healthcare encounter.
Not every medical error causes lasting harm; but others may lead to extended time in the hospital, additional treatment, longer recovery periods, or, in the worst cases, disability or death. The good news is that a number of organizations and groups, as well as healthcare professionals, are working to improve the safety of our healthcare system. Moreover, as patients and family caregivers, we can take action to help prevent medical errors.
Defining Medical Errors
Medical errors may be defined as errors of commission (doing the wrong thing); errors of omission (not doing the right thing); or mistakes in execution (doing the right thing, but doing it incorrectly).
In practical terms, however, medical error has come to encompass a range of causes that can lead to unintended outcomes:
• Never events: As defined by the National Quality Forum, these are preventable events considered so harmful that they should never occur. Also called serious reportable events (SREs), they include most medication errors as well as instances of performing surgery on the wrong body part or the wrong patient.
• Complications of care: Healthcare-associated complications, including infections that patients develop while in the hospital, are thought to be largely preventable.
• Miscommunication: Breakdowns in communication can result in the wrong treatment, a lack of treatment, or incorrect self-care by the patient. Miscommunication can be the result of faulty systems (poor methods of reporting critical test results, for example); lack of attention to the health literacy of patients; or a lack of cultural competency on the part of the healthcare team.
Given this broad landscape, researchers have struggled to come up with reliable estimates of how many medical errors occur each year. Most serious discussions of medical error still reference the 1999 Institute of Medicine report To Err Is Human, which estimated that between 44,000 and 98,000 deaths and more than one million injuries are caused annually by medical errors.
With the growth of the patient safety movement, government, industry, and private organizations have developed tools to help healthcare providers report and measure medical errors. The idea is that only by reporting errors can we begin to understand the scope of the problem and how errors happen; and only then can we develop solutions to improve patient safety.
What’s clear is that patient safety is a concern in any healthcare setting:
• A recent study reported in the journal Health Affairs estimates that as many as one of every three patients suffers an error during a hospital stay.
• A study that looked at malpractice claims — one method of analyzing medical errors — notes that more claims were paid for errors in the outpatient setting (doctors’ offices, clinics, etc.), an indication that they might be even more common than inpatient errors (hospitals).
• Transitions in care — when a patient is discharged from the hospital, moved from one hospital unit to another, or transferred from the hospital to a nursing or rehab facility — are particularly error-prone times for patients. This is when a communication breakdown between two separate teams can lead to confusion and missed care.
Most experts agree that faulty systems are often at the core of medical errors. One study of missed diagnoses found that, on average, three things “went wrong” along the way. Experts encourage healthcare organizations to foster blame-free workplaces so that staff will be more likely to report missteps and “near misses.” Likewise, many organizations have emphasized a “culture of mindfulness,” so that everyone is on the lookout for potential errors.
Making Patients and Caregivers Part of the Team
One of the positive outcomes of the increased emphasis on patient safety is that the relationship between providers and patients is changing. In 2000, the National Patient Safety Foundation’s Patient and Family Advisory Council published a white paper, National Agenda for Action: Patients and Families in Patient Safety — Nothing About Me, Without Me. The paper called for hospitals, health systems, and providers to involve patients and families in patient safety efforts. Recently, efforts to engage patients and families in all aspects of their healthcare have grown.
A 2005 study found that among a group of hospitalized patients who reported errors, only 55 percent of those errors were noted in the medical record, and none was noted in the hospital’s incident reporting system. The conclusion: Patients need to participate to provide the complete picture of safety failures.
Family caregivers, too, should be aware and alert to possible safety issues. The good news is that we are learning more every day, and there are already considerable resources to help family caregivers keep up to date.
Diane C. Pinakiewicz, MBA, is president of the National Patient Safety Foundation.
Resources
To read more about patient and family involvement in patient safety, check the following resources:
• National Patient Safety Foundation’s Web site offers a number of fact sheets for patients and families, as well as the Universal Patient CompactTM, designed to foster strong collaboration between patients and providers. Go to www.npsf.org.
• The Agency for Healthcare Research & Quality offers tips for healthcare consumers at www.ahrq.gov/consumer/safety.html.
• The Centers for Disease Control and Prevention offers “Ten Things You Can Do to Be a Safe Patient.” Go to www.cdc.gov/Features/PatientSafety.
• The National Institutes of Health offers Medline Plus, a library of health information, including patient safety tips in multiple languages. Find this information at www.nlm.nih.gov/medlineplus/patientsafety.html.
• The Joint Commission, an organization that sets standards and accredits hospitals and care facilities, provides a series of videos for patients and families called “Speak Up.” View the videos at www.jointcommission.org/multimedia/speak-up-prevent-errors-in-your-care-/ .
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