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.
Patient Safety And Human Factors Engineering Spring2006Carolyn Jenkins
The second Power Point in a 3 part seminar for nursing students during their medical surgical clinical rotation.
Adapted from Dr. John Gosbee MD, MS
VA National Center for Patient Safety
Tool Kit Available at www.patientsafety.gov in 2005.
Risk Management Training Slides.
Slides prepared based on "The Healthcare Quality Handbook" by Janet A Brown. Very useful health care quality reference for CPHQ exam preparation. For more slides, contact ckmujeeb@hotmail.com
2010 Honda Insight Hybrid San FernandoMiller Honda
2010 Honda Insight Hybrid color brochure provided by Miller Honda of Van Nuys located near San Fernando, CA. Find the 2010 Honda Insight Hybrid for sale in California; call about our current sales and incentives at (800) 980 5028.
Patient Safety And Human Factors Engineering Spring2006Carolyn Jenkins
The second Power Point in a 3 part seminar for nursing students during their medical surgical clinical rotation.
Adapted from Dr. John Gosbee MD, MS
VA National Center for Patient Safety
Tool Kit Available at www.patientsafety.gov in 2005.
Risk Management Training Slides.
Slides prepared based on "The Healthcare Quality Handbook" by Janet A Brown. Very useful health care quality reference for CPHQ exam preparation. For more slides, contact ckmujeeb@hotmail.com
2010 Honda Insight Hybrid San FernandoMiller Honda
2010 Honda Insight Hybrid color brochure provided by Miller Honda of Van Nuys located near San Fernando, CA. Find the 2010 Honda Insight Hybrid for sale in California; call about our current sales and incentives at (800) 980 5028.
2010 Accord Sedan color brochure provided by Miller Honda of Van Nuys located near San Fernando, CA. Find the 2010 Honda Accord Sedan for sale in California; call about our current sales and incentives at (800) 980 5028.
Medication error is a most common problem in a health care organisation.Its prevention can improve patient satisfaction,organisation brand value and bottom line.
Suicide in a hospital is known risk factor and recognized as sentinel event by JCI &NABH. Health care provider should know what to do in a post suicdide scenario.
Enrollment Is The Start Not The End 2010 Mhs Conference Jan 27Kevin Berry
Presented during the 2010 MHS Conference. The Mission of the MHS is to provide Joint Force Commanders military medical capability for the National Defense, National Security and National Health. Military Treatment Facility leaders can find enrollment optimize solutions through mission analysis.
patient safety and staff Management system ppt.pptxanjalatchi
Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care.
patient safety and staff Management system ppt.pptxanjalatchi
What is Patient Safety? Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care.
November 1999I N S T I T U T E O F M E D I C I N E S.docxIlonaThornburg83
November 1999
I N S T I T U T E O F M E D I C I N E
Shaping the Future for Health
TO ERR IS HUMAN:
BUILDING A SAFER HEALTH SYSTEM
Health care in the United States is not as safe as it should be--and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have
been prevented, according to estimates from two major studies. Even using
the lower estimate, preventable medical errors in hospitals exceed attributable
deaths to such feared threats as motor-vehicle wrecks, breast cancer, and
AIDS.
Medical errors can be defined as the failure of a planned action to be
completed as intended or the use of a wrong plan to achieve an aim. Among
the problems that commonly occur during the course of providing health care
are adverse drug events and improper transfusions, surgical injuries and
wrong-site surgery, suicides, restraint-related injuries or death, falls, burns,
pressure ulcers, and mistaken patient identities. High error rates with serious
consequences are most likely to occur in intensive care units, operating rooms,
and emergency departments.
Beyond their cost in human lives, preventable medical errors exact
other significant tolls. They have been estimated to result in total costs (in
cluding 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. Errors also are costly in terms of loss
of trust in the health care system by patients and diminished satisfaction by
both patients and health professionals. Patients who experience a long hospi
tal stay or disability as a result of errors pay with physical and psychological
discomfort. Health professionals pay with loss of morale and frustration at
not being able to provide the best care possible. Society bears the cost of er
rors as well, in terms of lost worker productivity, reduced school attendance
by children, and lower levels of population health status.
A variety of factors have contributed to the nation’s epidemic of medi
cal errors. One oft-cited problem arises from the decentralized and frag
mented nature of the health care delivery system--or “nonsystem,” to some
observers. When patients see multiple providers in different settings, none of
whom has access to complete information, it becomes easier for things to go
Errors…are costly
in terms of loss of
trust in the health
care system by pa
tients and dimin
ished satisfaction
by both patients
and health profes
sionals.
Types of Errors
Diagnostic
Error or delay in diagnosis
Failure to employ indicated tests
Use of outmoded tests or therapy
Failure to act on results of monitoring or testing
Treatment
Error in the performance of an operation, procedure, or test
Error in administering the treatment
Error in the dose or method of using a drug
Avoidable delay in treatmen.
Current Situation of Medical ErrorsPrepared byAsOllieShoresna
Current Situation of Medical Errors
Prepared by Asma Alshammari Alhanoof Alaniz Teflah Ali Mai Alrweeli Munyfaa Aldhafeeri Norah Almoteri
Introduction
Health care processes are increasingly being implicated in causing harm to patients. Medical errors and adverse events are primarily responsible for this harm. These errors, which may occur at every level of the custom are both common and diverse in nature.
Medical errors can occur anywhere in the health care system in hospitals, clinics, surgery centers, doctors' offices, nursing homes, pharmacies, and patients' homes and can have serious consequences. Errors can involve medicines, surgery, diagnosis, equipment, or lab reports.
Medical errors represent a serious public health problem and pose a threat to patient safety. As health care institutions establish “error” as a clinical and research priority, the answer to perhaps the most fundamental question remains elusive: What is a medical error? To reduce medical error, accurate measurements of its incidence, based on clear and consistent definitions, are essential prerequisites for effective action.
Despite a growing body of literature and research on error in medicine, few studies have defined or measured “medical error” directly. Instead, researchers have adopted surrogate measures of error that largely depend on adverse patient outcomes or injury (i.e., are outcome-dependent).
A lack of standardized nomenclature and the use of multiple and overlapping definitions of medical error have hindered data synthesis, analysis, collaborative work and evaluation of the impact of changes in health care delivery.
Medical error is defined as “failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim”. A medical error is a threat to patient safety and has a negative effect on health as well.
Definition of Medical Error
Medical error the term “error” has been variously defined. The Oxford Dictionary of Current English (1998) defines it as “mistake” or the condition of being morally “wrong”. Error has also been defined in a wider context as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim (Reason, 1990). Although the definition of “error” has its origins in behavioral psychology, the term is appropriate for medical usage. Using Reason's definition, IOM has tried to separate medical error into two parts (Kohn et al., 2000): the first half of the definition constitutes “error of execution” and the latter half, “error of planning.” In this context, two other related terms, “adverse event” and “patient safety.” Bates et al. (1997) defined adverse events as injuries that result from medical management, rather than from the underlying disease. Patient safety, as defined by IOM, is freedom from accidental injury (Kohn et al., 2000). All three terms, “medical error,” “adverse event,” and “patient safety” complement one another.
Type ...
Chapter 9 Patient Safety, Quality and ValueHarry Burke MD P.docxmccormicknadine86
Chapter 9: Patient Safety, Quality and Value
Harry Burke MD PhD
Learning Objectives
After reviewing the presentation, viewers should be able to:
Define safety, quality, near miss, and unsafe action
List the safety and quality factors that justified the clinical implementation of electronic health record systems
Discuss three reasons why the electronic health record is central to safety, quality, and value
List three issues that clinicians have with the current electronic health record systems and discuss how these problems affect safety and quality
Describe a specific electronic patient safety measurement system and a specific electronic safety reporting system
Describe two integrated clinical decision support systems and discuss how they may improve safety and quality
Patient Safety-Related Definitions
Safety: minimization of the risk and occurrence of patient harm events
Harm: inappropriate or avoidable psychological or physical injury to patient and/or family
Adverse Events: “an injury resulting from a medical intervention”
Preventable Adverse Events: “errors that result in an adverse event that are preventable”
Overuse: “the delivery of care of little or no value” e.g. widespread use of antibiotics for viral infections
Underuse: “the failure to deliver appropriate care” e.g. vaccines or cancer screening
Misuse: “the use of certain services in situations where they are not clinically indicated” e.g. MRI for routine low back pain
Introduction
Medical errors are unfortunately common in healthcare, in spite of sophisticated hospitals and well trained clinicians
Often it is breakdowns in protocol and communication, and not individual errors
Technology has potential to reduce medical errors (particularly medication errors) by:
Improving communication between physicians and patients
Improving clinical decision support
Decreasing diagnostic errors
Unfortunately, technology also has the potential to create unique new errors that cause harm
Medical Errors
Errors can be related to diagnosis, treatment and preventive care. Furthermore, medical errors can be errors of commission or omission and fortunately not all errors result in an injury and not all medical errors are preventable
Most common outpatient errors:
Prescribing medications
Getting the correct laboratory test for the correct patient at the correct time
Filing system errors
Dispensing medications and responding to abnormal test results
5
While many would argue that treatment errors are the most common category of medical errors, diagnostic errors accounted for the largest percentage of malpractice claims, surpassing treatment errors in one study
Diagnostic errors can result from missed, wrong or delayed diagnoses and are more likely in the outpatient setting. This is somewhat surprising given the fact that US physicians tend to practice “defensive medicine”
Over-diagnosis may also cause medical errors but this has been less ...
Chapter 9 Patient Safety, Quality and ValueHarry Burke MD P.docxtiffanyd4
Chapter 9: Patient Safety, Quality and Value
Harry Burke MD PhD
Learning Objectives
After reviewing the presentation, viewers should be able to:
Define safety, quality, near miss, and unsafe action
List the safety and quality factors that justified the clinical implementation of electronic health record systems
Discuss three reasons why the electronic health record is central to safety, quality, and value
List three issues that clinicians have with the current electronic health record systems and discuss how these problems affect safety and quality
Describe a specific electronic patient safety measurement system and a specific electronic safety reporting system
Describe two integrated clinical decision support systems and discuss how they may improve safety and quality
Patient Safety-Related Definitions
Safety: minimization of the risk and occurrence of patient harm events
Harm: inappropriate or avoidable psychological or physical injury to patient and/or family
Adverse Events: “an injury resulting from a medical intervention”
Preventable Adverse Events: “errors that result in an adverse event that are preventable”
Overuse: “the delivery of care of little or no value” e.g. widespread use of antibiotics for viral infections
Underuse: “the failure to deliver appropriate care” e.g. vaccines or cancer screening
Misuse: “the use of certain services in situations where they are not clinically indicated” e.g. MRI for routine low back pain
Introduction
Medical errors are unfortunately common in healthcare, in spite of sophisticated hospitals and well trained clinicians
Often it is breakdowns in protocol and communication, and not individual errors
Technology has potential to reduce medical errors (particularly medication errors) by:
Improving communication between physicians and patients
Improving clinical decision support
Decreasing diagnostic errors
Unfortunately, technology also has the potential to create unique new errors that cause harm
Medical Errors
Errors can be related to diagnosis, treatment and preventive care. Furthermore, medical errors can be errors of commission or omission and fortunately not all errors result in an injury and not all medical errors are preventable
Most common outpatient errors:
Prescribing medications
Getting the correct laboratory test for the correct patient at the correct time
Filing system errors
Dispensing medications and responding to abnormal test results
5
While many would argue that treatment errors are the most common category of medical errors, diagnostic errors accounted for the largest percentage of malpractice claims, surpassing treatment errors in one study
Diagnostic errors can result from missed, wrong or delayed diagnoses and are more likely in the outpatient setting. This is somewhat surprising given the fact that US physicians tend to practice “defensive medicine”
Over-diagnosis may also cause medical errors but this has been less.
This presentation has the measures to be taken for the safety of patients. It covers the 6 goals
Goal 1: Identify patients correctly
Goal 2: Improve effective communication
Goal 3: Improve the safety of high-alert medications
Goal 4: Ensure safe surgery
Goal 5: Reduce the risk of health care-associated infections
Goal 6: Reduce the risk of patient harm resulting from falls
Managing the unexpected in
a healthcare organisation is a
challenging and arduous task.
Experience of other
industries like aviation, nuclear
power etc. have proved that
it is possible to achieve this.
Hospital administrator should
ensure that clear, early,
complete and simple financial
communication is provided
both at the admission and
at the discharge occasion to
create patient-friendly financial
services for customer delight.
This effort shall enhance
both the brand value and
bottom line of the healthcare
organisation
Manpower is a
Health care organisation’s greatest asset and the development
of this asset is critical for
continued financial health of
the organisation
Health care organisation should provide top priority to the health hazards resulting from use of malfunctioning equipment in the present era of medical
device driven healthcare.
Clinical Audit is a method of confirming the quality of clinical services and identify the need for improvement. A skill hospital administrator should learn and practice.
The implementation of Risk management in a health care organisation ensure safe health care,increased patient satisfaction , improved bottom line and brand value.
In the present era of Pvt Health care industry in India with rising penetration of health care insurance,the need of Revenue Cycle Management is of paramount importance for organisation bottom line
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Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
We understand the unique challenges pickleball players face and are committed to helping you stay healthy and active. In this presentation, we’ll explore the three most common pickleball injuries and provide strategies for prevention and treatment.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
Struggling with intense fears that disrupt your life? At Renew Life Hypnosis, we offer specialized hypnosis to overcome fear. Phobias are exaggerated fears, often stemming from past traumas or learned behaviors. Hypnotherapy addresses these deep-seated fears by accessing the subconscious mind, helping you change your reactions to phobic triggers. Our expert therapists guide you into a state of deep relaxation, allowing you to transform your responses and reduce anxiety. Experience increased confidence and freedom from phobias with our personalized approach. Ready to live a fear-free life? Visit us at Renew Life Hypnosis..
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
the IUA Administrative Board and General Assembly meeting
Medical error health bizindia april-11-page-1
1. 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 problem
Medical 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
2. 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 errors
Active 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)
3. Inadequate systems of communication
Inadequate maintenance of equipment and buildings
Barrier/Defence
In 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 risks
Practitioners 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.
4. Step 2: Determining the cause
Practitioners 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 consequences
The 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 incident
Then the practitioners should take a view about, how likely it is that the practice will be
exposed to the risk
Step 5: Determining the risk
Once 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 controls
Having 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 plan
The 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 error
Joint 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 safety
Strategies 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
5. 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 system
Errors 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
Conclusion
Healthcare 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