This document discusses medical errors and increasing patient safety. It summarizes several studies that found medical errors are common, with rates of adverse events from around 3-17% of hospital admissions. Errors result in tens of thousands of unnecessary deaths annually. Most errors are due to cognitive mistakes and "system" failures rather than individual negligence. To improve safety, the document argues we must think of errors as systems failures and implement strategies like checklists, standardized procedures, training, and a culture where safety is a top priority and errors are reported to fix underlying issues rather than blame individuals.

1. Reducing medical error and
increasing patient safety
Richard Smith
Editor, BMJ

2. What I want to talk about
• A story
• How common is error?
• Why does error happen?
• How should we think of error?
• How should we respond?

3. A story

4. How common is error?
• Harvard Medical Practice Study
• Reviewed medical charts of 30 121
patients admitted to 51 acute care
hospitals in New York state in 1984
• In 3.7% an adverse event led to
prolonged admission or produced
disability at the time of discharge
• 69% of injuries were caused by errors

5. How common is medical error?
• Australian study
• Investigators reviewed the medical records
of 14 179 admissions to 28 hospitals in New
South Wales and South Australia in 1995.
• An adverse event occurred in 16.6% of
admissions, resulting in permanent
disability in 13.7% of patients and death in
4.9%
• 51% of adverse events were considered to
have been preventable.

6. How common is medical error?
• The differences between the US and
Australian results may reflect
different methods or different rates
• Other, smaller studies (including
one from Britain) show similar
orders of errors
• There are few studies from
outpatients or primary care

7. How common is medical error?
• An evaluation of complications
associated with medications among
patients at 11 primary care sites in
Boston.
• Of 2258 patients who had had drugs
prescribed, 18% reported having had a
drug related complication, such as
gastrointestinal symptoms, sleep
disturbance, or fatigue in the previous
year.

8. Results of medical error
• In Australia medical error results in
as many as 18 000 unnecessary
deaths, and more than 50 000
patients become disabled each year.
• In the United States medical error
results in at least 44 000 (and
perhaps as many as 98 000)
unnecessary deaths each year and 1
000 000 excess injuries.

9. Types of error
• About half of the adverse events
occurring among inpatients resulted
from surgery.
• Next come
– Complications from drug treatment
– therapeutic mishaps
– diagnostic errors were the most common
non-operative events. In the Australian
study cognitive errors, such as making an

10. Types of error
• Cognitive errors--such as incorrect
diagnosis or choosing the wrong
medication-- more likely to have
been preventable and more likely to
result in permanent disability than
technical errors.

11. Which patients are most at risk?
• Those undergoing cardiothoracic
surgery, vascular surgery, or
neurosurgery
• Those with complex conditions
• Those in the emergency room
• Those looked after by inexperienced
doctors
• Older patients

13. How dangerous is health care?
• Less than one death per 100 000 encounters
– Nuclear power
– European railroads
– Scheduled airlines
• One death in less than 100 000 but more than 1000
encounters
– Driving
– Chemical manufacturing
• More than one death per 1000 encounters
– Bungee jumping
– Mountain climbing
– Health care

14. Why do errors happen?
• All humans make errors: indeed, “the
ability to make mistakes” allows human
beings to function
• Most of medicine is complex and uncertain
• Most errors result from “the system”--
inadequate training, long hours, ampoules
that look the same, lack of checks, etc
• Healthcare has not tried to make itself safe

16. How to think of error?
• An individual failing
– Only the minority of cases amount from
negligence or misconduct; so it’s the
“wrong” diagnosis
– It will not solve the problem--it will
probably in fact make it worse because it
fails to address the problem
– Doctors will hide errors
– May destroy many doctors inadvertently
(the second victim)

17. How to think of error?
• A systems failure
–This is the starting point for
redesigning the system and
reducing error

18. How to respond? Tactics
• Reduce complexity
• Optimise information processing
– checklists, reminders, protocols
• Automate wisely
• Use constraints
– for instance, with needle connections
• Mitigate the unwanted side effects of change
– with training, for example.

19. Building a safe healthcare
system (from James Reason)
• Principles
• Policies
• Procedures
• Practices

20. Building a safe healthcare
system (from James Reason)
• Principles
– Safety is everybody’s business
– Top management accepts setbacks and
anticipates errors
– safety issues are considered regularly
at the highest level
– Past events are reviewed and changes
implemented

21. Building a safe healthcare
system (from James Reason)
• Principles
– After a mishap management concentrates on
fixing the system not blaming the individual
– Understand that effective risk management
depends on the collection, analysis, and
dissemination of data
– Top management is proactive in improving
safety--seeks out error traps, eliminates
error producing factors, brainstorms new
scenarios of failure

22. Building a safe healthcare
system (from James Reason)
• Policies
– Safety related information has direct
access to the top
– Risk management is not an oubliette
– Meetings on safety are attended by staff
from many levels and departments
– Messengers are rewarded not shot
– Top managers create a reporting culture
and a just culture

23. Building a safe healthcare
system (from James Reason)
• Policies
– Reporting includes qualified
indemnity, confidentiality, separation
of data collection from disciplinary
procedures
– Disciplinary systems agree the
difference between acceptable and
unacceptable behaviour and involve
peers

24. Building a safe healthcare
system (from James Reason)
• Procedures
– Training in the recognition and recovery of
errors
– Feedback on recurrent error patterns
– An awareness that procedures cannot
cover all circumstances; on the spot
training
– Protocols written with those doing the job
– Procedures must be intelligible, workable,
available

25. Building a safe healthcare
system (from James Reason)
• Procedures
– Clinical supervisors train their
charges in the mental as well as the
technical skills necessary for safe
and effective performance

26. Building a safe healthcare
system (from James Reason)
• Practices
– Rapid, useful, and intelligible feedback on
lessons learnt and actions needed
– Bottom up information listened to and
acted on
– And when mishaps occur
• Acknowledge responsibility
• Apologise
• Convince patients and victims that lessons
learned will reduce chance of recurrence

27. James Reason’s bottom line
• Fallibility is part of the human
condition
• We can’t change the human
condition
• We can change the conditions under
which people work

28. Conclusions
• Human beings will always make errors
• Errors are common in medicine,
killing tens of thousands
• We begin to know something about the
epidemiology of error, but we need to
know much more
• Naming, blaming and shaming have no
remedial value

29. Conclusions
• We need to design health care
systems that put safety first
(First, do no harm)
• We know a lot about how to do
that
• It’s a long, never ending job