The document lists the top 15 causes of death in the United States from 2012-2013. Heart disease was the leading cause, resulting in over 611,000 deaths. The other top causes were malignant neoplasms, chronic lower respiratory diseases, accidents, cerebrovascular diseases, Alzheimer's disease, and diabetes. Notably, the document estimates that medical errors are the third leading cause of death in the US, causing between 210,000-400,000 deaths annually. This high rate of medical errors occurs due to a combination of active human errors by providers as well as latent errors in systems, processes, and organizational culture. Reducing medical errors requires understanding both individual and systemic factors that contribute to errors.

1. Diseases
of
Heart
Malignant
neoplasms
Medical
Errors
Chronic
Lower
Respiratory
Diseases
Accidents
(Uninten>onal
injuries)
Cerebrovascul
ar
diseases
Alzheimer's
disease
Diabetes
mellitus
Influenza
and
pneumonia
Nephri>s,
nephro>c
syndrome
and
nephrosis
Inten>onal
self-­‐harm
(suicide)
Deaths
611,105
584,881
305,000
149,205
130,557
128,978
84,767
75,578
56,979
47,112
41,149
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
Number
of
Deaths
Deaths
in
the
United
States
(2012-­‐2013)
Primum non nocere: (“First, do no harm”)
Applying Business Principles to Analyze Medical Errors
By: Hadiqa Memon, Dr. Elizabeth Anderson-Fletcher
DEFINING MEDICAL ERRORS
PROBLEM STATEMENT:
Medical errors received national attention in the early 2000s
after the Institute of Medicine published To Err is Human:
Building a Safer Health System. In this report, researchers argued
that medical errors were the eighth leading cause of death.
They estimated that 44,000 to 98,000 deaths occur annually in
the United States as the result of medical errors (Kohn et al.,
2000).
A decade later, medical errors are growing in concern, and are
estimated to be the third leading cause of death in the United
States (James, 2013). While there are many organizations trying
to find ways to improve patient safety, there is still much left in
explaining medical errors.
MEASURING MEDICAL ERRORS
CURRENT STATISTICS
IMPROVING QUALITY
HOW DO ERRORS OCCUR?
PROPOSED MODEL:
REFERENCES:
CONCLUSION:
KEY FINDINGS:
Case: Description:
Betsy Lehman
Dana-Farber
Cancer Institute
(Boston, MA)*
• 39-year old health reporter for the Boston
Globe was diagnosed with breast cancer in
September 1993
• She began her third round of chemotherapy
on November 14, 1994.
• On December 2, Lehman’s electrocardiogram
revealed low potassium levels, for which she
was prescribed potassium supplements.
• On December 3, Lehman died due to
accidental overdose of chemotherapeutic drug
(Cytoxan).
• On February 13, 1995, data clerk found that
Lehman’s death resulted from a medical error.
Thomas E.
Duncan
Texas Health
Presbyterian
Hospital
(Dallas, TX)**
• A Liberian national who had unknowingly
contracted Ebola from a neighbor in
Monrovia on September 15, 2014.
• He arrived in Dallas on September 20.
• He began to feel ill on September 24 and went
to THPH emergency room on September 25.
• He was misdiagnosed to have a low-grade
virus and sent home with prescribed course of
antibiotic and Tylenol
• On September 28, his condition worsened and
he was placed in isolation.
• On September 30, he was diagnosed with
Ebola and later died on October 8.
• The two nurses treating Duncan were also
diagnosed with Ebola on October 12 and 15
and transfered to biocontainment units.
• Anderson-Fletcher, E., Vera, D., & Abbott, J. (2016). The Texas Health Presbyterian
Hospital Ebola Crisis: A Perfect Storm of Human Errors, Systems Failures, and Lack of
Mindfulness, Hobby Center for Public Policy White Paper, University of Houston.
• Bohmer, R., & Winslow, A. (1999). The Dana-Farber Cancer Institute, HBS Case.
• Classen, D. C., Resar, R., Griffin, F., Federico, F., Frankel, T., Kimmel, N., James, B.
C. (2011). “Global trigger tool” Shows that Adverse Events in Hospitals may be Ten
Times Greater than Previously Measured, Health Affairs, 30(4), 581–589.
• Deming, W. Edwards. (1986). Out of the crisis, Massachusetts Institute of Technology
Center for Advanced Engineering Study, Cambridge, MA.
• Heron, M. (2016). Deaths: Leading Causes for 2013, National Vital Statistics Reports,
The Centers for Disease Control and Prevention National Center for Health
Statistics, National Vital Statistics System, 65(2), 1–95.
• James, J. T. (2013). A New, Evidence-based Estimate of Patient Harms Associated
with Hospital Care, Journal of Patient Safety, 9(3), 122–8.
• Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (2000). To Err is Human: Building
a Safer Health System, Annales Francaises D’Anesthesie et de Reanimation (Vol. 21).
• Leape, L. (1994). Error in Medicine, Journal of American Medical Association, 272,
1851–1857.
• Maslow, a. H. (1943). A Theory of Human Motivation, Psychological Review, 50(13),
370–396.
• Reason, J. (2000). Education and Debate Human Error: Models and Management,
The British Medical Journal, 320, 768–770.
• Reason, J. (2001). Understanding Adverse Events: The Human Factor, In Vincent
C. (Ed.), Clinical Risk Management: Enhancing Patient Safety (pp. 9–30), London: BMJ
Books.
• Williams, C., Nelson, D. L., & Quick, J. C. (2012). Introduction to Organizational Behavior
and Management, (M. S. Maureen Staudt, Ed.), Mason: Cengage Learning.
• Wills, M. (2016). Personality Hardiness, Resilience, and Compassion Fatigue in Traumatic
Brain Injury Rehabilitation Workers, Honors Thesis, University of Houston.
CASE STUDIES:
*(Bohmer and Winslow, 1999) **(Anderson-Fletcher, Vera, & Abbott, 2016)
• Business principles of Management and Supply Chain offer
a new perspective to the current research in medical errors,
which can ultimately improve the quality of the healthcare.
• In order to reduce medical errors, it is essential to build a
culture of transparency, where errors are not a search for the
culprit, but a lesson from which to learn and improve upon.
• Furthermore, it is essential to understand the needs of
healthcare professionals, by incorporating best practices from
the management literature to create satisfying occupations.
ACKNOWLEDGMENTS: This project was possible by the support of The University of Houston Honors College and The Office of Undergraduate Research.
94% of errors are attributed to the system,
while 6% are special cases. (Deming, 1986)
Understanding the needs of healthcare professionals:
• In the last fifty years, there has been a shift from outcome-dependent to process-dependent approaches in defining the term
“medical errors”.
• The spontaneous nature of medicine has made measuring medical errors difficult. However, the Institute of Healthcare
Improvement has been developing and refining the Global Trigger tool to obtain a better estimate.
• Based on the estimates from the Global Trigger tool, medical errors are the third leading cause of death. Despite the growing
concern of medical errors, the National Vital Statistics fails to report adverse medical events.
• It is essential to understand that human errors are part of larger system failures in the healthcare industry.
• The culture of medicine is synonymous with the “culture of blame.” Attention has been focused on finding the person
responsible for the error, rather then understanding what caused the error.
• Management literature offers new perspective in improving the quality of healthcare service.
Institute for Healthcare Improvements
Global Trigger tool (90%)
Deviation from the process of care,
which may or may not cause harm
to the patient.
(Reason, 2001)
Agency for Healthcare
Research and Quality’s
Patient Safety Indicators
(9%)
Hospital
Voluntary
Reporting
System (1%)
Effectiveness of current measuring tools:
Factors that affect healthcare employee productivity:
OCCUPATIONAL PHYSIOLOGICAL PERSONAL
• Work Environment
• Culture of Medicine,
“Culture of Blame”
• Occupational Stress
• Communication
Barriers
• Management vs.
Clinical
• Shift Cycle
• Sleep Patterns
• Nutrition
• Exercise, Physical
Activity
• General Health and
Wellness
• Family
Responsibilities
• Personal
Responsibilities
• Relationship Status
• Children
• Work/Life Balance
• Educational Stress
• Financial Stress
• Job Satisfaction
• Increased Stress, High Cortisol Levels
• Exhausted Mental State
• Compassion Fatigue
• Burnout
Decreased Worker Productivity
and Work Quality
(Classen et al., 2011)
The failure of a planned action to be completed as
intended or the use of a wrong plan to achieve an aim, the
accumulation of errors results in accidents.
(Leape, 1994)
(Kohn et al., 2000)
Any combination of active or latent errors:
active errors: occur at the level of the frontline operator.
latent errors: tend to be removed from the direct control of
the operator and include practice, products, procedures,
and systems.
(Reason, 2000)
“Whenadoctorcannotdo good, he must be ke
ptfromdoingharm.”-Hippocrates
National Vital Statistics
(Heron, 2016)
Job Performance = Motivation x Ability x Situational Constraints
(Williams, Nelson, & Quick, 2012)
• Offering fair compensation and comfortable working
conditions.
• Safe working environment, job security, and fringe
benefits.
• Encouraging social interaction and cooperation, creating
stable group settings.
• Recognizing/rewarding outstanding performance, job
satisfaction/importance, giving employees responsibilities.
• Challenging employees’ abilities, providing opportunities
for advancement, encouraging creativity and high levels of
achievement.
Healthcare Quality Improvement
Organizations:
An act of omission or commission in planning or
execution that contributes to an unintended result.
MEDICAL ERRORS ALLEGEDLY
3RD
LEADING CAUSE OF DEATH
*An estimated 210,000 - 400,000 deaths annually in
the United States due to medical errors.
(James, 2013)
(Maslow, 1943)
(Williams, Nelson, & Quick, 2012; Wills, 2016)
Deaths in the United States (2012-2013)
NumberofDeaths
BETSY LEHMAN THOMAS DUNCAN
Nurses
used to
unusual drug
dosage, therefore
administered
treatment based
on protocol.
Physician
unaware of
prescription
protocol used
by nurses.
Lehman’s
symptoms
understood as
side effects for
her treatment.
Duncan’s
misdiagnosis
exacerbates his
symptoms.
Miscommunication
between physicians
and nurses.
Electronic
form did not
immediately
highlight
Duncan’s
travel.
Self-
Actualization
Self-Esteem
Belonging
Safety/Security
Physiological
Adverse
events as
a result of
medical
errors.