1. Medical Errors Frances Symons PHE 570

2. Definition- Medical Error Failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. For example: an adverse drug event, improper transfusion, surgical injuries and wrong site injuries, suicide, restraint-related injury or death, falls, burns, pressure ulcers and mistaken patient identity. At least 44,000- 98,000 people die in hospitals each year from preventable medical errors. (Institute of Medicine, 1999)

3. Background Before the 1990’s- perfect performance was expected and felt to be achievable through education, professionalism, vigilance and care –Lead to fear of retribution and drove errors underground Mid 1990’s- providers were starting to acknowledge human fallibility and the impossible task of perfect performance –Did not confront individuals who willfully made unsafe choices and put the patient at risk (Institute for Safe Medication Practices, 2006)

4. Costs of a Medical Error IOM in 1999 issued a report estimating total costs (including the expense of additional care necessitated by the errors, lost income and household productivity, and disability) of between $17 billion and $29 billion per year in hospitals nationwide. Medication Errors –each preventable adverse drug event that took place in a hospital added about $8,750 (2006 dollars) to the cost of a hospital stay. –400,000 of these events occur each year (IOM, 2006)

5. After an Error Occurs Patient faces a lack of productivity, loss of quality of life, depression, traumatization and may increase their fear of an error in the future. What about the health care provider? –Physicians felt upset and guilty about harming the patient, disappointed about failing to practice medicine to their own high standards, fearful about a possible lawsuit and anxious about the error’s repercussions regarding their reputation (Gallagher et al., 2003). –Physicians struggle with forgiving themselves for what happened and some turned to a trusted colleague, significant other or the affected patient to seek forgiveness through disclosure (Gallagher et al., 2003).

6. Disclosure of an Error “In aviation it is not merely the pilot who is responsible for the outcomes of a flight; it is the pilot, the air traffic controllers, the maintenance crew, the stewards, and the ground staff-in other words, the aviation system. Thus, neither the last person to touch the controls nor the last person to touch the patient is fully and solely responsible for the outcome, good or bad” (Liang, 2002). Blame for a medical error can not be placed on one person

7. Disclosure There is a broad definition of a medical error by both providers and patients, the process of disclosing an error is even more muddled. Physicians say their worst fear about errors included lawsuits, loss of patient trust, the patient informing friends about their bad experience, loss of colleagues’ respect, and diminished self- confidence (Gallagher et al., 2003). Patients believed the error disclosure would improve their trust in their providers’ honesty and would reassure them that they were receiving complete information about their overall care (Gallagher et al., 2003).

8. Disclosure Physicians while striving to be truthful, were reluctant to provide patients with basic information concerning their error (Gallagher et al., 2003). The fear of confession is appropriate concerning the shame and blame still pervasive within the healthcare system and could imply fault.

9. Fixing Healthcare All healthcare schools should educate about medical errors –Prevention –Disclosure –Understanding themselves Emotional support needs to be available Clear definition of medical error –Basis for reporting across America –Make reporting mandatory –Use and “error investigation team”

10. Questions? What are your recommendations for the healthcare system?

11. Websites of Interest Agency for Health Care Research and Quality: http://www.ahrq.gov/http://www.ahrq.gov/ Oregon Patient Safety Commission: http://www.oregon.gov/OPSC/index.sht ml