Errors in medical practice

•Patient safety represents a central concept of quality in healthcare. One of the greatest
threats to quality and patient safety is medical error. Injury can range from minor to severe
incidents, including death.

•It is the 3rd leading cause of death in the United States, responsible for approx. 200,000
deaths per year.

What is a medical error?

•Error can be defined as the accidental failure to perform an action as intended (e.g., misdosing
the appropriate drug) or accidentally performing the incorrect action (e.g., prescribing the wrong
drug), which could potentially result in harm to the patient.

•Medical errors should be differentiated from healthcare violation. Errors are unintentional or
accidental whereas violations are conscious and deliberate deviation from standards, laws, or
rules (someone does something and knows it to be against the rules). Even if the doctor commits
a violation out of well-intention it is still a violation rather than an error.

•For example, a physician decides not to enter a patient’s allergies into the electronic record due
to time constraints in starting treatment. If this act led to an adverse reaction due to a missed
allergic reaction, it would technically be considered a violation and not an error.

What are the consequences of medical errors?

On patients:
Errors may result in adverse events or near-misses.

Adverse event: any harm resulting from medical management rather than an underlying disease.
An adverse event may or may not be the result of a medical error. A sentinel event is a wholly
unexpected or unacceptable adverse event that results in serious injury or death of a patient

Near miss (close call): a medical error that could have resulted in an adverse event but did not,
either incidentally or due to a timely intervention (e.g., a nurse identifies that a doctor's order is
incorrect)

Health care system:

Inefficiency and increased cost.

What is the value of studying medical errors?

Ethically:
The main ethical issues involved are as follows:

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1. Patient autonomy
•Medical professionals may find it difficult to admit their errors in front of patients, their families,
and colleagues. However, medical errors should be disclosed to promote public trust, justice and
prevention of further harm to patients.

•Non-disclosure of error will delay efforts to identify the faults and weaknesses in the health
care processes, thereby exposing more patients to harm.

2. Beneficence of the patient and non-maleficence

•Understanding medical error and the science of patient safety can help us design a health care
system capable of getting it right every time

3. Justice:

•Patients need their rights and right to compensation. There should be efficient procedures to
support patients and their rights.

Legally:
•Doctors should be aware of common medical errors, their causes and how to prevent them,
to avoid falling into malpractice lawsuits.

What are the common types of medical errors?

According to its effect (now or later):

Active error:
•Error at the direct level of contact between healthcare personnel and patients. Has an
immediate impact on the patient. Examples: Surgery on the incorrect site, Wrong route of drug
administration

Latent error:
•Error that could contribute to patient harm. Latent error in conjunction with active error can
lead to an adverse event. Examples: Flaws in hospital organization, Implementation of new
equipment without adequate staff training

According to the stage at which the error occurs:

Diagnostic:
• account for at least 17% of preventable errors in hospitalized patients

• Wrong or delayed diagnosis

• Failure to employ indicated tests

• Use of outmoded tests or therapy

• Failure to act on results of monitoring or testing

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Treatment:
•Delayed treatment: Failure to admit to hospital when necessary and avoidable delay in
treatment.

•Wrong treatment:

Drugs: incorrect type, quantity, or route.

Surgery or procedure: wrong technique, site, side, patient, left instrument.

Preventive:
•Failure to provide prophylactic treatment

•Inadequate monitoring or follow-up of treatment

•System failure: failure in equipment and system maintenance

•Others: e.g., Failure of communication

Another classification of medical errors is:

Actions do not go as intended:

•Slips: actions not carried out as intended or planned, e.g., injecting a medication intravenously
when you meant to give it subcutaneously. Slips are observable.

•Lapses: missed actions and omissions (e.g., forgetting to monitor and replace serum potassium
in a patient treated with furosemide for acute congestive heart failure).

Mistakes: the intended action is wrong

•A faulty plan or incorrect intentions; (e.g., treating a patient for suspected pneumonia when
the patient was misdiagnosed and actually has a pulmonary embolism).

How do medical errors occur?

•Medical errors occur due to the complexity of the health care system, together with the
potential for mistakes due to human nature.

Medical error may be in the form of:

•Individual error: medical error resulting from the failure of a single healthcare professional
due to negligence

•Systems error: medical error resulting from: a) a series of flaws in technical and organizational
design and/or decision-making, and b) from failure to recognize and mitigate hazards and risks
in the healthcare setting. Approximately 80% of medical errors or adverse patient events are
system-derived.

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Risk factors of medical errors:
1.Poor individual conditions (cognitive errors): e.g., fatigue, stress, illness, drugs, alcohol,
unhealthy/inadequate diet).

2.Sometimes, the clinician holds on to a particular diagnosis falling into bias. Types of bias
include:

•Anchoring bias: the clinician holds on to a particular diagnosis (usually the initial one).

•Confirmation bias, looking for evidence to support a pre-conceived opinion, rather than
looking for evidence that refutes it or provides greater support to an alternative
diagnosis, may accompany an anchoring error. Clinicians should regard conflicting data
as evidence for the need to continue to seek the true diagnosis rather than as
anomalies to be disregarded.

•Availability bias is the tendency to assume a diagnosis based on recent patient

encounters or memorable cases.

3.Communication failures: Errors at the. time of transitions or handoffs between nurses and
between residents. e.g.:

Illegible handwriting (e.g., on order sheets or prescription pads)

Lack of standardized terminology and use of jargon

Lack of personnel skilled in foreign languages

Improper documentation (e.g., patient allergies)

4.Teamwork failures: lack of coordination between members of the patient care team.
Inconsistency in team membership. Lack of role clarity. Conflict. Complacency

5.Poor working conditions (system-related errors): e.g., overworked staff, time pressures, lack
of safety protocols, or lack of appropriate supervision.

6.Masked manifestations of a disease or uncooperating patient (no-fault errors).

Swiss cheese model:

•The Swiss cheese model illustrates how any safety system (slice of cheese) will have flaws
(holes), either due to active failure or latent conditions, that allow errors or hazards to pass
through safeguards and cause harm.

•The multiple slices reduce the risk of error and harm by ensuring that if a hazard manages to
pass through a hole in one layer, a subsequent layer will likely block its further passage through
the system.

•When the flaws in the individual layers align, a hazard or error can result in harm.

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How to avoid medical errors?
1.Physicians should know the limits of their ability & training

2.Physicians should assess their fitness to attend to patient care. This mnemonic can help in
assessment:

IM SAFE

I: Illness (Are you suffering from an illness that is degrading your performance?)

M: Medications (Are you taking medications that may impair your judgment?)

S: Stress (Are you adequately managing the stressors in your life?)

A: Alcohol (Are you using alcohol in excess with negative consequences?)

F: Fatigue (Are you getting enough rest?)

E: Eating (Are you maintaining a healthy diet?)

3.Training & education: Medical-error rounds (on weekly or monthly basis) provide an
opportunity for review and reflection on medical practice with resultant plan for changes in
processes and procedures.

4.Effective communication: Evidence shows that effective communication between team

members lead to better outcomes and fewer errors. Using techniques of structured
communication (e.g., SBAR, call-backs) can help safeguard against errors.

5.Improving teamwork: Teamwork training to reduce the potential for patient harm by
developing effective communication skills, a supportive working environment, and an
atmosphere in which all team members feel comfortable speaking up when they suspect a
problem. Team members are trained to check each other’s actions, help when needed, and
address errors in a nonjudgmental fashion. Teamwork training should include huddles, briefs,
debriefs and feedback.

6.Documentation

7.Health care professionals need to be educated about medical error identification and
importance of near misses.

8.System approach to medical error:

•Avoid bad apples/blame culture: this approach does not improve safety; creates culture of fear;
causes of error are not addressed.

•System approach focuses on finding out how the error occurred, rather than who did it, and
fixing the system to prevent further similar errors.

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•Examples of system-based redesigns for patient safety include removing look-alike drugs from
the nursing unit to prevent medication errors OR using a standardized preoperative checklist to
help operating room staff review critical information prior to surgery

•Medical error analysis to identify, either retrospectively or prospectively, risks in a healthcare

system that may lead to errors and violations.

a) Retrospective analysis: is called root cause analysis (RCA);

Definition: a retrospective analysis performed after a medical error has occurred in order to
identify the (root) causes of the error and implement measures to prevent recurrence.

Procedure of RCA:

Identify the medical error (“what happened?”) and analysis of all possible factors that could have
led to the error

Identify what could have prevented the error from occurring (“why did it happen?”) Tool used:
Fishbone diagram (Ishikawa diagram, OR cause and effect diagram)

Implement preventive measures (“what can be done to prevent recurrence?”) Examples:

updating technology, employing double checks, using checklists, staff education on new policies

b) Prospective approach: failure mode effects analysis (FMEA): aims to identify possible
weak points in the system in order to develop strategies to prevent the errors from
occurring in the future. It is usually used to anticipate potential factors that could go
wrong when a new procedure, technique, or protocol is to be implemented in clinical
practice.

Procedure of FMEA:

Identify what could go wrong (failure mode)

Identify why it could go wrong (failure causes)

Identify the outcomes of the potential failures (failure effects)

Proactive implementation of corrective measures

9. Use ergonomics

•Definition: The design and engineering of equipment, systems, processes, methods, and
environments to fit the individuals who interact with them with the goal of reducing error
while improving efficiency, productivity, safety, and comfort.

•Safety risks can be minimized by:

a.Forcing functions: Equipment, process, method, or system design features that prevent error
by forcing the best option by default. Most effective technique for minimizing adverse events,
as it inhibits a chain of action that cause or perpetuate error.

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Examples:

Anesthesia gas cylinders with gas-specific nozzles for different gases

Software that prevents incorrect dosages of drugs and warns the user of potential
adverse reactions or interactions.

Avoiding shared storage of drugs with similar labels or names

b.Standardization: The development and implementation of standards that apply to

various aspects of a process or system.

Examples:

Standardized protocols and guidelines: help ensure a consistent level of quality

Standardized equipment: facilitates use across a system

Standardized checklists: help prevent common errors

Standardized terminology: helps prevent communication errors

c.Simplification: The reduction of complexity of equipment, systems, and processes.

Examples:

Ordering laboratory tests electronically

Streamlining administration

Example of a common error:

•Medication errors represent one of the most common causes of preventable patient harm. An
estimated 1.5 million deaths occur each year in the United States due to medication error.

•Common causes of medication error:

Poor handwriting technique on a prescription pad or order form, resulting in a pharmacist

or nurse administering the wrong drug or wrong dose

Dosing or route of administration errors

Failure to identify that given patient is allergic to a prescribed medication

Look-alike or sound-alike drugs (e.g., rifampin/rifaximin)

•Strategies that help to reduce or prevent medication errors are as follows.

a.The 5 Rs help to confirm several key points before the administration of any medication.

–Right drug

–Right patient

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 –Right dose

–Right route

–Right time

b.Computerized physician order entry (CPOE) involves entering medication orders directly into a
computer system rather than on paper or verbally. The computer software (i.e., electronic health
record) can automatically check for prescribing errors or allergies.

What to do if errors have already occurred? (Responding to

medical errors)
a.Implement corrective measures immediately to minimize patient harm.

b.Disclose the nature of the error

•Disclose errors to the patient and, if necessary, a senior medical professional.

Near-misses do not generally need to be disclosed.

•Medical errors should be disclosed in order to:

promote public trust in the physicians and the system

prevent further harm to a patient and to other patients, thus improve the safety of
medical practice

respect personal autonomy

support the principle of justice (compensation).

•An error disclosure should include the following 3 elements:

1- Accurate description of the events and their impact on the patient (in a simple way and avoid
being defensive or evasive).

2-Sincere apology showing care and compassion, with offers of support and fair compensation
(avoid over blaming yourself or the others)

3-Assurance that appropriate steps are being taken to prevent the adverse event from
happening to another patient in the future

•Disclosure should take place at the right time, when the patient is medically stable enough to
absorb the information, and in the right setting (privately, better with other team members).

•Try to avoid reacting to the charged response that such disclosure might generate. During the
meeting with the patient or his family members, keep eye contact, be on the same level, avoid
medical jargon, be clear and give time for questions.

c.Reporting:

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•Reporting errors to the health care system (to redesign system to avoid future errors).

•If a physician believes that a colleague has committed an error in a patient's care, the physician
should urge their colleague to report this error to the patient.

•If the colleague refuses, the physician should report this error via their institution’s standard
protocol.

•Although near misses (errors that occur but fortunately do not result in patient harm) do not
generally need to be disclosed to patients, they should still be reported to the system so that
they, too, can be studied. One person’s near-miss may be the next person’s fatal error.

•In order to be effective, reporting must be safe. Individuals who report incidents must not be
punished or suffer other ill effects from reporting. The identities of reporters should not normally
be disclosed to third parties.

•Barriers to reporting errors: fear of punishment/ legal claims, the belief that that no corrective
action, the failure to recognize that an error has occurred.

N.B. Medical team: when errors occur, team members tend to blame one another. Stressed by
a medical error, they lack the necessary skills to discuss the error as a team in a nonjudgmental
and supportive fashion. Team communication that is respectful and provides support for one
another creates the environment for delivering the same kind of respectful and supportive care
of patients.

References:
Kaabba A. F. A. (2015): Medical malpractice and medical errors. In: Professionalism and Ethics
Handbook for Residents, a Practical Guide. The Saudi Commission for Health Specialties, KSA,
Pp: 67 - 71.

Levinson W., Ginsburg S., Hafferty F. W. et al. (2014): Understanding medical professionalism.
Lange, McGraw hill education.

Kaplan’s Behavioral and Social Sciences book (2018): Basic Science of Patient Safety. Pp: 149-
162.

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