MEDICALERRORSPrepared By Dr. Anees AlSaadiCommunity Medicine Resident R3Jan. 2013
OUTLINE• Definitions Related To Medical Errors.• Classification.• Burden Of The Medical Errors.• Settings And The Most Common Type.• Factors Result In Medical Errors.• Prevention of The Medical Errors.
Medical Errors• SIDE EFFECTS.• MEDICAL ERROR.• SENTINEL EVENTS.• RISK THEREOF.• MEDICATION ERRORS.
MEDICAL ERROR• Failure to complete aplanned action as intendedor the use of a wrong planto achieve an aim.• Preventable.• Where … ?• Which step of healthcare provision?• What if notpreventable. ..?
MEDICAL ERROR• What Are the Types of Medical Errors …..How Can we Classify Medical Errors. ..?
SENTINEL EVENTS.• Immediate investigation.• An unexpected occurrenceinvolving death or seriousphysical, psychological injury.Examples
RISK THEREOF.• Recognition of a variation inprocess when an unanticipatedrecurrence carries the risk of aserious adverse outcome.Examples
MEDICATION ERRORS.– Adverse Event.– Adverse drug Reaction.– Unexpected adverse drugreaction.– Serious adverse event or adversedrug reaction.What AboutSIDEEFFECTS…?
Burden of the Medical Errors• Realization.• Knowledge.• Underreporting.• Management and Political.
Burden of the Medical ErrorsHow Many of You Know or Had ComeCross Any Medical Errors. …..?
“We have an epidemic of medicalmalpractice, not of malpracticelawsuits.”University of Pennsylvania lawprofessor Tom BakerTom Baker, The Medical Malpractice Myth, 2005.
Burden of the Medical Errors• (2004) HealthGrades report stated that annualdeaths attributable to medical errors may be ashigh as 195,000 deaths.• This number compared to other causes ofdeath is exceeded only by heart disease(700,142) and cancer (553,768).HealthGrades. In-Hospital Deaths from Medical Errors at 195,000 Per Year, HealthGrades Study Finds. Available athttp://www.healthgrades.com/media/DMS/pdf/InhosptialDeathsPatientSafetyPres sRelease072704.pdf.
Burden of the Medical Errors• The Institute of Medicine’s(IOM) estimated as many as98,000 people die every yearat a cost of $29 billion.1 To Err Is Human: Building a Safer Health System, Institute of Medicine, 19992 Deaths/Mortality, 2005, National Center for Health Care Statistics at the Centers for Disease Control, viewed athttp://www.cdc.gov/nchs/fastats/deaths.htm.
Burden of the Medical Errors• (2010) Department of Health and HumanServices found one in seven Medicarerecipients.• Accountable for an estimated 180,000 patientsdeaths annually.
Burden of the Medical Errors• 37.6 $ billion each year and about 17$ billion ofthese costs are directly associated with medicalerrors that are preventable.http://www.vantageproed.com/mederrors/mederrorsc.htm
Burden of the Medical Errors• Indirect cost:– patient:• Family.• Job.–Health Care Provider.
What IsThe Most CommonTypes OfMedical Errors …. .?
The Most Common Type• Wrong-site surgery (13.4%)• Patient suicide (11.9%)• Operative & postoperative complications (10.8%)• Delay in treatment (8.6%)• Medication errors (8.1%)• Patient falls (6.4%)An analysis of sentinel events reported to the Joint Commission from 1995 to March 31, 2010 :
Medication Errors• Rheumatoid arthritis Patientdied after receiving anoverdose of methotrexate--a10-milligram Daily DoseOf The Drug Rather ThanThe Intended 10-milligram Weekly Dose.
Medication Errors• One patient died because20 units of insulin wasabbreviated as "20 U,"but the "U" was mistakenfor a "zero." As a result,a dose of 200 units ofinsulin was accidentallyinjected.
Causes Of Medical Errors• Researchers for The Journal of the AmericanMedical Association:–Reluctance of doctors to admit errors .–Lack of leadership .–Insurance reimbursement system.HealthGrades Report, The HealthGrades Patient Safety Study, [Website] Accessed October 12, 2009.http://www.healthgrades.com/media/DMS/pdf/InhosptialDeathsPatientSafetyPressRelease072704.pdf
Causes Of Medical Errors• Incomplete patient information.• Unavailable drug information.• Miscommunication.• Lack of appropriate labeling.• Environmental factors.
Causes Of Medical ErrorsDonald M. Berwick Administrator ofthe Centers for Medicare andMedicaid Services. USA.“The leading cause of medical mistakes as theincreasing complexity of health care”
Prevention• It is simply NOT ACCEPTABLE for patientsto be harmed by a health care system that isthere to offer healing and comfort.
Prevention• There is no one single solution to this on-goingproblem but rather MANY SOLUTIONSAND SYSTEMS that must be in place andworking properly to decrease the risk ofmedical errors.
Prevention• The focus must not be ON BLAMINGINDIVIDUALS but on LEARNING FROMPAST errors and preventing future ones.
Prevention• Agency for HealthCare Research anQuality (AHRQ). 30 Safe Practices forimproving patient safety.• Systems provided by Organizations:–The Leapfrog Group.–Joint Commission on Accreditation ofHealthCare Organizations (JCAHO).–Hospital Medication Error Management.(CPOE)
PreventionNine Patient Safety Solutions:• Look-Alike, Sound-Alike Medication Names.• Patient Identification.• Communication During Patient Hand-Overs.• Performance Of Correct Procedure At CorrectBody Site.• Control Of Concentrated Electrolyte Solutions.2 May 2007 | Washington/Geneva - WHO is today launching "Nine patient safety solutions"
PreventionNine Patient Safety Solutions:• Patient Identification.• Communication During Patient Hand-Overs.• Performance Of Correct Procedure At CorrectBody Site.• Control Of Concentrated Electrolyte Solutions.2 May 2007 | Washington/Geneva - WHO is today launching "Nine patient safety solutions"
PreventionNine Patient Safety Solutions:• Medication Accuracy At Transitions In Care.• Avoiding Catheter And Tubing Misconnections.• Single Use Of Injection Devices.• Improved Hand Hygiene To Prevent Health Care-Associated Infection.2 May 2007 | Washington/Geneva - WHO is today launching "Nine patient safety solutions"
Summary• Medical error of great importance due to high burden.• Ongoing problem worldwide but it is preventable.• Most common in hospitals & in psychiatric units.• Wrong site in surgery is the most common.• Prevention is one single solution to this on-goingproblem but rather many solutions and systems andlearning from the past errors.
• HIPPOPOTOMONSTROSESQUIPPEDALIOPHOBIA• Fear of long words.• • ARACHIBUTYROPHOBIA• Fear of peanut butter stickingto the roof of the mouth.