This article discusses the causes and management of medical errors. A medical error is defined as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim”. The classification includes several categories of mistakes. Approximately 3% to 25% of hospitalized patients in developed countries have been reported to suffer from adverse events, partly due to medical errors. Several approaches have been suggested for prevention at organizational, team, and individual levels. Response to medical errors by healthcare providers and physicians’ attitude are described. Finally, ethical and legal aspects of medical errors are mentioned briefly. The topic has implications for the practice of neurology.
| || |
• Medical errors are an important issue in the practice of medicine, and this applies to neurology as well.
| || |
• Physicians should become familiar with causes of medical errors and methods of preventing them.
| || |
• Medical errors have legal and ethical implications.
Historical note and terminology
The concept of harm resulting from medical treatment is more than 3500 years old. The Code of Hammurabi in the seventh century BC prescribed penalties for physician errors that resulted in harm. Similarly, the Roman law in the first century AD included penalties for such harms. Complications of medical treatment have been described by great medical writers throughout the past centuries and are now referred to as iatrogenic. Adverse effects of treatment such as adverse drug reactions are taken into consideration in risk/benefit analysis so that the physician as well as the patient can make an informed decision.
“Miss Nightingale’s Scheme for Uniform Hospital Statistics,” the culmination of Florence Nightingale's mid-19th-century work analyzing surgical outcomes, is widely regarded as 1 of the earliest efforts at standardizing care to reduce medical error. Thorough but overly complicated, it was abandoned soon after its adoption. In the early 20th century, Dr. Ernest Amory Codman, an orthopedic surgeon at Massachusetts General Hospital, developed his “End Result System,” a series of note cards used to track a patient’s symptoms, procedure, and outcome to improve his techniques and avoid errors. A derivative of this system was subsequently included in the 1916 publication of the American College of Surgeons’ Standards for Hospital Practice. The first meeting of the Anesthesia Mortality Committee in Philadelphia in 1935 was aimed at improving patient outcomes (25). Aside from these sporadic efforts, the field of “medical errors” received little systematic analysis for most of the 20th century.
A medical error is defined by the Institute of Medicine as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim” (ie, error of planning or of execution) (16). Errors that do not result in harm to a patient are known as “near-misses.” An adverse event is an untoward medical occurrence during treatment and may be due to an underlying condition. It may or may not be the result of a medical error.
The Joint Commission on Accreditation of Health Care Organizations, which is involved in patient safety in the United States, recommends careful investigation and analysis of a Patient Safety Event (not primarily related to the natural course of the patient’s illness or underlying condition) if it becomes a sentinel event, ie, it causes severe temporary harm or permanent harm or death. The Joint Commission adopted a formal Sentinel Event Policy in 1996 to help hospitals that experience sentinel events to protect the patient, improve systems, and prevent further harm.
In the 20th century, most physicians did not regard medical errors as a major cause of morbidity. This changed at the start of the 21st century, when the Institute of Medicine published “To Err is Human,” a landmark report detailing the frequency of medical errors and the importance of reducing them (16). Medical error is the third leading cause of death in the United States. Considerable regulatory, administrative, research, media, and public attention has focused on medical errors as a distinct and important topic under the umbrella of quality improvement in healthcare. Medical errors have ethical and legal implications that will be discussed in separate articles on these topics.
Two major types of errors are:
| || |
1. Errors of omission occur as a result of actions not taken. Examples are not strapping a patient into a wheelchair or not stabilizing a gurney prior to patient transfer.
| || |
2. Errors of the commission occur as a result of the wrong action taken. Examples include administering a medication to which a patient has a known allergy or not labeling a laboratory specimen that is subsequently ascribed to the wrong patient.