Special Feature

Dealing with Medical Errors

By : Dr. AK Khandelwal

Newspaper and television stories of catastrophic injuries occurring at the hands of clinicians bring to highlight the problem of medical errors, but they provide little insight into its nature or magnitude. In reality, these horrific cases that make the headlines are just the tip of the iceberg. Medical errors are ubiquitous and their subsequent costs (human and financial) are substantial.

Medical errors are a serious threat to patient safety in both hospitals and in the community. Greater public awareness of clinical error combined with rapidly increasing litigation and insurance costs have created a pressing need to implement risk management in hospitals to improve patient safety.

Magnitude of problemMedical error is the third most frequent cause of death in Britain after cancer and heart disease and kills four times more people than any other kind of accidents.

Around 850,000 medical errors occur per year resulting in up to 40,000 unintended patient deaths plus other harm in UK. The annual costs of "loss" is estimated to be around 20% of budget to NHS organisations, UK.

Patients injured as a result of a medical error spend longer time in hospital and have higher hospital costs. E.g. the length of stay increased by 1.9 to 2.2 days as a result of adverse drug events in Utah and Harvard studies.

Brennan et al, reviewed the medical charts of 30,121 patients admitted to 51 acute care hospitals and found that 69% of injuries were caused by errors. The Harvard study of medical practice and a study of the quality of Australian healthcare, have found that

medical errors occur in 4-17 % of admissions and 30-51 % of these adverse events were considered to be preventable and represent suboptimal care.

A report from the Institute of Medicine, USA, states that around 1,00,000 patients a year die from preventable errors in hospitals in America. Donchin et al have reported that 1.7 errors per patient per bed occurred in a medical-surgical intensive care unit, by an observational study at university hospital in Israel

What are medical errors?Error: Failure of a planned action to be completed as intended (error of execution) or use of a wrong plan to achieve an aim (error of planning); the accumulation of errors results in accidents.

Active error: An error that occurs at the level of the frontline operator and whose effects are felt almost immediately.

Latent error: Errors in the design, organisation, training, or maintenance that lead to operator errors and whose effects typically lie dormant in the system for lengthy periods of time.

Mechanism of errorsActive failures

Active failures are unsafe acts or omissions committed by those whose actions can have immediate adverse consequences. The term active failures includes:

Action slips or failures, such as picking up the wrong syringe Cognitive failures, such as memory lapses and mistakes through ignorance or

misreading a situation "Violations"deviations from safe operating practices, procedures, or standards.

Latent failures Latent failures stem from fallible decisions, often taken by people not directly involved in the workplace. In medicine, latent failures would be primarily the responsibility of management and of senior clinicians at those times when they are taking decisions on the organisation of their unit.

Latent failures provide the conditions in which unsafe acts occur; these work conditions include:

Heavy workloads Inadequate knowledge or experience Inadequate supervision A stressful environment Rapid change within an organisation Incompatible goals (for example, conflict between finance and clinical need)

Inadequate systems of communication Inadequate maintenance of equipment and buildings

Barrier/DefenceIn industries, and to a lesser extent in medicine, defences exist to guard against human error and aid recovery from potential problems. In other industries, this might be a failsafe device to shut down a reactor, in medicine the warning sound of a monitor alerting an anaesthetist to falling blood pressure

Contributing factors

Human failure: 46% Technical failure: 27% Organisational failures: 27% 

Although we cannot change the aspects of human cognition that make us to err, we can design systems that reduce error and make them safer for patients, and in turn will even reduce errors due to gaps in human cognition

Medical errors can occur anywhere in the health care system, at hospitals or at patients’ homes. Errors can involve: medicines, surgery, diagnosis, equipment, lab reports, etc.

They can happen during even the most routine tasks, such as when a hospital patient on a salt-free diet is given a high-salt meal. Errors also happen when doctors and their patients have problems communicating.

Medical practitioners rely heavily on their administrative support staff for the smooth running of their practice. In many practices, systems have developed by evolution rather than design. Some work perfectly well but others may have inherent faults that are only exposed when a problem occurs. Medical errors frequently result from interactions between the host (patient), the environment (healthcare system), and the vector (often the healthcare workers) of transmission. The Institute of Medicine report suggests that environmental (healthcare system) factors may be the most important contributors to medical error causation.

Development of Standard Operating Procedures (SOP's) for each function/area in the hospital and induction training will prevent errors to a great extent.

Approaches to reduce medical errors

Step 1: Identifying risksPractitioners examine the processes within their work and identify the key operational risks, e.g., systems for repeat prescriptions, handling of test results, checking instruments before and after surgery, receipt of telephone messages, and so on.

Step 2: Determining the causePractitioners then identify the sort of situations that could cause a breakdown in care. For example, the absence of a system ensuring that the test results are seen and acted upon before being filed.

Step 3: Considering the consequencesThe consequences for the practice of each risk are then assessed. These are likely to include injury/harm to patients or staff; death and damage to reputation.

Step 4: Assessing the likelihood of an adverse incidentThen the practitioners should take a view about, how likely it is that the practice will be exposed to the risk

Step 5: Determining the riskOnce the consequences and likelihood of system failure in each of the areas identified has been assessed, it is then possible to rate the risks in order of significance. Obviously, the highest rating would be given to system failures with the worst consequences and the greatest likelihood of occurring.

Step 6: Identifying and reviewing controlsHaving identified and assessed the risks, practitioners review the controls that are already in place. Are they adequate? How can they be improved? Do new controls need to be introduced?

Step 7 : Action planThe practice now understands where risks lie and the controls needed for managing them. A clear action plan for improvement can now be drawn up for introducing new and better controls/systems for managing risk. e.g., development of standard operating procedures.

Analysis of medical errorJoint Commission on the Accreditation of Healthcare Organizations (JCAHO) mandated the use of Root Cause Analysis in the investigation of sentinel events in accredited hospitals. Root Cause Analysis provide a structured and process-focused framework with which to approach sentinel event analysis. Systems and organizational issues can be identified and addressed, and active errors acknowledged..

Systems factors and safetyStrategies for the design of safe systems of care should focus on:

Preventing errors Making errors visible –Detection Mitigating the effects of error

Tactics to reduce errors

Reducing complexity Optimise information processing Automate wisely Use constraints Mitigate the unwanted side effects of change

Deploy these to support any of the three strategic components of error prevention, detection, and mitigation. Review and renew them based on the organisational performance feedback.

Redesign systemErrors made by an individual often reflect system-wide problems. The correct response is to redesign systems so that errors are acknowledged, detected, intercepted, and mitigated. Trying harder will not work, changing systems of care will. Systems should be designed to catch error as early as possible

ConclusionHealthcare institutions of today are complex matrix organisations. Errors are bound to occur in any complex human endeavour, and healthcare is no exception. Medical errors are ubiquitous and the costs (human and financial) are substantial. The top priority must be to redesign systems geared to prevent, detect and minimise effects of undesirable combinations of design, performance, and circumstance.

Safety improvement through system monitoring and feedback, and system and process redesign from aviation and nuclear power industries hold many lessons for healthcare. Healthcare institutions with patient safety as high priority should have a blame-free, non-punitive system for reporting errors in medical care to peer-review protected committees that are empowered to institute changes for system-wide improvements to prevent future errors.

The author is the Medical Director at AnandaLoke Hospital & Neuroscieneces Centre