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SCHS Topic6: Medical Errors

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PEER (Professionalism and Ethics Education for Residents) Project sponsored and organized by the Saudi Commission for Health Specialties (SCHS).
Definitions of terminology related to Medical Error (ME)
Levels of severity of medical error
Types & Examples of medical errors
Causes of ME
Disclosure of ME
Prevention of Medical Error

SCHS Topic6: Medical Errors

  1. 1. Asst. Prof., Dept. of Medical Ethics King Fahad Medical City – Faculty of Medicine King Saud Bin Abdul-Aziz University for Health Sciences Dr. Ghaiath M. A. Hussein Professionalism and Ethics Education for Residents (PEER) Medical Errors
  2. 2. Outline  Definitions of terminology related to Medical Error (ME)  Levels of severity of medical error  Types & Examples of medical errors  Causes of ME  Disclosure of ME  Prevention of Medical Error
  3. 3. Definitions of Medical Error  The failure of a planned action to be completed as intended, or as the use of a wrong plan to achieve an aim.  A preventable adverse effect of care, whether or not it is evident or harmful to the patient.  This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment.
  4. 4. More Definitions  ME: An act or omission that would have been judged wrong by knowledgeable peers at the time it occurred  Adverse Event: An unplanned or unusual deviation in the patient care  Sentinel Event : An event which has resulted in an unanticipated death or major permanent loss of function, not related to the natural course of the patient's illness or underlying condition.
  5. 5. Levels of Severity of ME Level 1: An event occurred that resulted in the need for increased patient assessments, but no change in vital signs and no patient harm. Level 2: An event occurred that resulted in the need for treatment and/or intervention and caused temporary patient harm. Level 3: An event occurred that resulted in initial or prolonged hospitalization, and caused temporary harm.
  6. 6. Levels of Severity of ME Cont… Level 4: An event occurred that resulted in permanent patient harm or near death event, such as anaphylaxis. Level 5: Any set of circumstances (exclusive of the disease or condition in which the patient is being treated) which significantly increases the likelihood of a serious adverse outcome. Level 6: An event occurred that resulted in patient death. *Levels 3 through 6 shall be discussed with patient or families.
  7. 7. Types and Examples of Medical Errors EXAMPLEERROR Missed diagnosisDiagnosis or evaluation Inappropriate or premature dischargeMedical decision-making Waiting when treatment is indicatedTreatment Incorrect dosageMedication Failure to review treatment planInadequate supervision Failure to convey informationFaulty communication Faulty techniqueProcedural complications Inappropriate or premature dischargeMedical decision-making *Wu AW, McPhee SJ, and Christensen JF. Mistakes in Medical Practice, Chapter 32 in Behavioral Medicine in Primary Care. 1997 Appleton and Lange, Stamford, CT. Edited by MD Feldman and JF Christensen. *Adapted, with permission, from Wu AW at al: Do house officers learn from their mistakes? JAMA 1991; 265:2089. American Medical Association
  8. 8. Common Causes of Medical Mistakes  Ignorance  Inexperience  Faulty judgment  Hesitation  Fatigue  Job overload  Breaks in concentration  Faulty communication  Failure to monitor closely  System flaws *Wu AW, McPhee SJ, and Christensen JF. Mistakes in MedicalPractice,Chapter 32 in Behavioral Medicine in Primary Care. 1997 Appleton and Lange, Stamford, CT. Edited by MD Feldman and JF Christensen.
  9. 9. Simple Truths about Medical Mistakes 1. Errors will happen. Since no human is infallible, errors are bound to happen, and this includes physicians. 2. Since errors can be expected, systems must be designed to prevent and absorb them.
  10. 10. Simple Truths about Medical Mistakes Cont. 3. Errors are not synonymous with negligence. Medicine’s ethos of infallibility leads, wrongly, to a culture that sees mistakes as an individual problem and remedies them with blame and punishment instead of looking for root causes and fixing problems by improving systems. 4. Creating a culture supportive of errors reporting is the starting point in reducing future medical errors.
  11. 11. Disclosing Error to Patients  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.
  12. 12. Disclosing Error to Patients Cont.  Outline a plan of care to rectify the harm and prevent recurrence.  Offer to get prompt second opinions where appropriate.  Offer the option of a family meeting and the option of having lawyers present.  Document important discussions.
  13. 13. Disclosing Error to Patients Cont.  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. Hébert PC, Levin AV, and Robertson G. CMAJ 2001:164; 509-513
  14. 14. Prevention of Medical Errors Examples in medical practiceError prevention measures include Checklists, flow sheets, tickler systems Reduced reliance on memory Handheld computer, electronic medical records Improved information access Fail-safe to avoid prescribing two drugs that interact fatally Error-proofing systems. Office formularies, guidelines synthesis Standardization Staff in services.Training on error identification and prevention
  15. 15. Questions for Discussion  How do I decide whether to tell a patient about an error?  Do physicians have an ethical duty to disclose information about medical mistakes they, or their colleagues, did to their patients?  Won't disclosing mistakes to patients undermine their trust in physicians and the medical system?  By disclosing a mistake to my patient, do I risk having a malpractice suit filed against me?  What if I see someone else make a mistake? http://depts.washington.edu/bioethx/topics/mistks.html
  16. 16. THANKS FOR YOUR ATTENTION

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