Medical errors

1. Medical errors
Dr. Shazia Iqbal
Assistant Professor Director of Medical
Vision College of Medicine, Riyadh
siqbal@vision.edu.sa
View my Linkedin Profile
https://www.researchgate.net/profile/Shazia_Iqbal7
https://orcid.org/0000-0003-4890-5864

2. • Discuss What are medical errors
• Enlist Types of medical errors
• Discuss Why medical errors happens
• Discuss Should we tell truth to the patient
• Discuss How can we reduce errors in the health
profession
Objectives

4. An error
An error is ‘something incorrectly done through ignorance or inadvertence; a mistake, e.g. in calculation,
calculation, judgement, speech, writing, action, etc. or ‘a failure to complete a planned action as intended,
intended, or the use of an incorrect plan of action to achieve a given aim.
Medical Error
Is the failure in the treatment process that leads to, or has the potential to lead to, harm to the patient.
patient.
Near Miss: incidence about to happen but by chance didn't occur.
Sentinel event: A sentinel event is an unexpected occurrence involving death or serious physical or
psychological injury.
Definition

5. Types of medical errors

6. Causes of medical errors
1- Complexity of healthcare
• The interaction of drugs with complex technologies.
• Staying in hospital for long periods of time.
• Multidisciplinary approach
2- System and process design
• Inadequate communication
• Unclear lines of authority

7. Causes of medical errors
3- Environmental factors.
• Services congestion
• unsafe care provision areas
• poorly designed areas for safe monitoring.
4- Infrastructure failure.
• Lack of documentation process
• Lack of continuous improvement process

8. Causes of medical errors
5- Human factors and work environment

13. 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)

22. 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”

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

25. 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).

26. Tell the truth
Notify your professional insurer and seek assistance from
those who might help you with disclosure (e.g., unit director,
risk manager). Disclose promptly what you know about the
event. Concentrate on what happened and the possible
consequences. Take the lead in disclosure; don't wait for the
patient to ask
Offer the option of follow - up meetings. Be prepared for
strong emotions. Accept responsibility for outcomes, but
avoid attributions of blame. Apologies and expressions of
sorrow are appropriate.

27. Actions to reduce medical errors
• Greater focus on healthcare quality (performance measures
/ clinical reviews / quality in healthcare research)
• Mandatory accreditation process
• Patient safety standards / targets
• Computerized drug ordering systems
• Reporting errors should be voluntary and confidential
• insurance against malpractice
• Patient education

30. references
• https://pubmed.ncbi.nlm.nih.gov/29763131/
• https://www.uofmhealth.org/health-library/meder
• https://academic.oup.com/qjmed/article/102/8/513/159892
3
• https://www.nccmerp.org/about-medication-errors
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3211566/

32. thank you