1. MEDICAL ERRORS
BY
ROBERT SAIZI (Dip, BSc)

2. INTRODUCTION
Health care is not usually safe as it is intended
to be.
Everyday many people get injured and die in
hospitals silently as a result of preventable
medical error
In 1999, IOM published a landmark report “To
err is human”

3. Intro cont..
44000-98000 death/year in US
Estimated 275 death/day
 ME affect 1 in every 10 patients worldwide
Example:
A mix up of results in lab: a client who is HIV- is
issued HIV+ positive result.

4. Other examples..
Wrong treatment
Incorrect dosage
Incorrect route
Delay in treatment

5. Intro cont..
Patients have right to safe and effective care
at all times
H/W have legal obligation to provide safe care
Eg. Nonmaleficience and beneficence.

6. Incidence
Bangladesh- 75.3% of U/5 with acute diarrhoes
received inappropriate treatment (Alam et al
1998)
Nigeria- outpatients prescription common errors-
38% overdosage, 18% underdosage (Oshikoya &
Ojo, 2007)
Malaysia- common types of drug administration
errors- incorrect time 34%, followed by incorrect
technique of administration 22% (Chua et al 2009)

7. Incidence cont..
Malawi- 29% of uncomplicated malaria were
subjected to ME (Osterholt et al 2006)

8. MEDICAL ERROR is..
 A failure of planned action to be completed
as intended or
Use of the wrong plan to achieve an intended
aim

9. ADVERSE EVENT
Injury caused by medical management rather
than the underlying condition of the patient
NEGLIGENT ADVERSE EVENT
The care provided failed to meet the standard
of care reasonably expected of an average
physician qualified to take care of patients.

10. TYPES OF ERRORS
Skill based errors- slips/lapse-when the action
made is not what was intended
Rule based mistakes- actions that match
intentions but do not achieve their intended
outcome due to incorrect application of a rule
or inadequacy of the plan
Knowledge based mistakes- actions which are
intended but do not achieve the intended
outcome due to knowledge deficits

11. WHY DO WE SLIP/LAPSE
Distraction
Misattention
Fatique
Emotions: boredom,fear and anxiety, anger
Environment: noise and heat

12. SLIPS- EXAMPLE
• Order : 25mg IV diazpam stat
• Vial says 5mg/ml……5ml vial
• Brain computes 25mg= 5 vials instead of 5ml
• Nurse found a 25cc syringe and drew up
125mg

13. What do you REALLY think of this
nurse
Careless
Dangerous
Fatiqued

14. SYSTEMS TO REDUCE ERRORS
Complexity-too many steps, too many people
(communication issues)
Workload- too heavy or too light
(performance is best when worload is
moderate)
Poor design- Focus on functionality while
ignoring the real life user.
Interrruptions and distrations-frequaently
associated with errors- 50% in aviation

15. Cont..
Yet extremely common in healthcare-phycians
experience 10 interruptions per hour (chisolm
et al 2000)
Culture- authority structure impending
communication
No assignment of responsibility

16. TEST
ROW 1
ROW 2
ROW 3

17. WAY TO LEARN FROM ERRORS
Incidence reporting-reporting, monitoring and
analysing information about adverse events.
Root cause analysis- error is inevitable part of
human
Avoid reliance of memory
Use checklist or protocols
Always be watchful