Preventable adverse effect of medical care
A medical error is a preventable adverse effect of care ("iatrogenesis"), whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailments.
Definitions.
A medical error occurs when a health-care provider chooses an inappropriate method of care or improperly executes an appropriate method of care. Medical errors are often described as human errors in healthcare.
There are many types of medical error, from minor to major, and causality is often poorly determined.
There are many taxonomies for classifying medical errors.
Definitions of diagnostic error.
There is no single definition of diagnostic error, reflecting in part the dual nature of the word diagnosis, which is both a noun (the name of the assigned disease; diagnosis is a label) and a verb (the act of arriving at a diagnosis; diagnosis is a process). At the present time, there are at least 4 definitions of diagnostic error in active use:
Graber et al. defined diagnostic error as a diagnosis that is wrong, egregiously delayed, or missed altogether. This is a "label" definition, and can only be applied in retrospect, using some gold standard (for example, autopsy findings or a definitive laboratory test) to confirm the correct diagnosis. Many diagnostic errors fit several of these criteria; the categories overlap.
There are two process-related definitions: Schiff et al. defined diagnostic error as any breakdown in the diagnostic process, including both errors of omission and errors of commission. Similarly, Singh et al. defined diagnostic error as a "missed opportunity" in the diagnostic process, based on retrospective review.
In its landmark report, Improving Diagnosis in Health Care, The National Academy of Medicine proposed a new, hybrid definition that includes both label- and process-related aspects: "A diagnostic error is failure to establish an accurate and timely explanation of the patient's health problem(s) or to communicate that explanation to the patient." This is the only definition that specifically includes the patient in the definition wording.
Definition of prescription error.
A prescription or medication error, as defined by the National Coordinating Council for Medication Error Reporting and Prevention, is an event that is preventable that leads to or has led to unsuitable use of medication or has led to harm to the person during the period of time that the medicine is controlled by a clinician, the person, or the consumer. Some adverse drug events can also be related to medication errors.
Impact.
One extrapolation suggests that 180,000 people die each year partly as a result of iatrogenic injury. The World Health Organization registered 14 million new cases and 8.2 million cancer-related deaths in 2012. It estimated that the number of cases could increase by 70% through 2032. As the number of cancer patients receiving treatment increases, hospitals around the world are seeking ways to improve patient safety, to emphasize traceability and raise efficiency in their cancer treatment processes. Children are often more vulnerable to a negative outcome when a medication error occurs as they have age-related differences in how their bodies absorb, metabolize, and excrete pharmaceutical agents.
UK.
In the UK, an estimated 850,000 medical errors occur each year, costing over £2 billion (estimated in the year 2000). The accuracy of this estimate is not clear. Criticism has included the statistical handling of measurement errors in the report, and significant subjectivity in determining which deaths were "avoidable" or due to medical error, and an erroneous assumption that 100% of patients would have survived if optimal care had been provided.
A 2006 study found that medication errors are among the most common medical mistakes, harming at least 1.5 million people every year. According to the study, 400,000 preventable drug-related injuries occur each year in hospitals, 800,000 in long-term care settings, and roughly 530,000 among Medicare recipients in outpatient clinics. The report stated that these are likely to be conservative estimates. In 2000 alone, the extra medical costs incurred by preventable drug-related injuries approximated $887 million—and the study looked only at injuries sustained by Medicare recipients, a subset of clinic visitors. None of these figures take into account lost wages and productivity or other costs.
US.
According to a 2002 Agency for Healthcare Research and Quality report, about 7,000 people were estimated to die each year from medication errors – about 16 percent more deaths than the number attributable to work-related injuries (6,000 deaths). One in five Americans (22%) report that they or a family member have experienced a medical error of some kind. A 2000 Institute of Medicine report estimated that medical errors result in between 44,000 and 98,000 preventable deaths and 1,000,000 excess injuries each year in U.S. hospitals. A 2001 study in the "Journal of the American Medical Association" of seven Department of Veterans Affairs medical centers estimated that for roughly every 10,000 patients admitted to the select hospitals, one patient died who would have lived for three months or more in good cognitive health had "optimal" care been provided. A 2001 study estimated that 1% of hospital admissions result in an adverse event due to negligence. Identification or errors may be a challenge in these studies, and mistakes may be more common than reported as these studies identify only mistakes that led to measurable adverse events occurring soon after the errors. Independent review of doctors' treatment plans suggests that decision-making could be improved in 14% of admissions; many of the benefits would have delayed manifestations. Even this number may be an underestimate. One study suggests that adults in the United States receive only 55% of recommended care. At the same time, a second study found that 30% of care in the United States may be unnecessary. For example, if a doctor fails to order a mammogram that is past due, this mistake will not show up in the first type of study. In addition, because no adverse event occurred during the short follow-up of the study, the mistake also would not show up in the second type of study because only the principal treatment plans were critiqued. However, the mistake would be recorded in the third type of study. If a doctor recommends an unnecessary treatment or test, it may not show in any of these types of studies.
Cause of death on United States death certificates, statistically compiled by the Centers for Disease Control and Prevention (CDC), are coded in the International Classification of Disease (ICD), which does not include codes for human and system factors.
Causes.
The research literature showed that medical errors are caused by errors of commission and errors of omission. Errors of omission are made when providers did not take action when they should have, while errors of commission occur when decisions and action are delayed. Commission and omission errors have also been attributed with communication failures.
Medical errors can be associated with inexperienced physicians and nurses, new procedures, extremes of age, and complex or urgent care. Poor communication (whether in one's own language or, as may be the case for medical tourists, another language), improper documentation, illegible handwriting, spelling errors, inadequate nurse-to-patient ratios, and similarly named medications are also known to contribute to the problem. Misdiagnosis may be associated with individual characteristics of the patient or due to the patient multimorbidity. Patient actions or inactions may also contribute significantly to medical errors.
Healthcare complexity.
Complicated technologies, powerful drugs, intensive care, rare and multiple diseases, and prolonged hospital stay can contribute to medical errors. In turn, medical errors from carelessness or improper use of medical devices often lead to severe injuries or death. Since 2015, 60 injuries and 23 deaths have been caused by misplaced feeding tubes while using the Cortrak2 EAS system. The FDA recalled Avanos Medical's Cortrak system in 2022 due to its severity and the high toll associated with the medical error.
Complexity makes diagnosis especially challenging. There are less than 200 symptoms listed in Wikipedia, but there are probably more than 10,000 known diseases. The World Health Organization's system for the International Classification of Disease, 9th Edition from 1979 listed over 14,000 diagnosis codes. Textbooks of medicine often describe the most typical presentations of a disease, but in many conditions patients may have variable presentations instead of the classical signs and symptoms. To add complexity, the signs and symptoms of a given condition change over time; in the early stages the signs and symptoms may be absent or minimal, and then these evolve as the condition progresses. Diagnosis is often challenging in infants and children who can't clearly communicate their symptoms, and in the elderly, where signs and symptoms may be muted or absent.
There are more than 7000 rare diseases alone, and in aggregate these are not uncommon: Roughly 1 in 17 patients will be diagnosed with a rare disease over their lifetime. Physicians may have only learned a handful of these during their education and training.
System and process design.
In 2000, The Institute of Medicine released "To Err is Human," which asserted that the problem in medical errors is not bad people in health care—it is that good people are working in bad systems that need to be made safer.
Poor communication and unclear lines of authority of physicians, nurses, and other care providers are also contributing factors. Disconnected reporting systems within a hospital can result in fragmented systems in which numerous hand-offs of patients results in lack of coordination and errors.
Other factors include the impression that action is being taken by other groups within the institution, reliance on automated systems to prevent error., and inadequate systems to share information about errors, which hampers analysis of contributory causes and improvement strategies.
Cost-cutting measures by hospitals in response to reimbursement cutbacks can compromise patient safety.
In emergencies, patient care may be rendered in areas poorly suited for safe monitoring. The American Institute of Architects has identified concerns for the safe design and construction of health care facilities.
Infrastructure failure is also a concern. According to the WHO, 50% of medical equipment in developing countries is only partly usable due to lack of skilled operators or parts. As a result, diagnostic procedures or treatments cannot be performed, leading to substandard treatment.
The Joint Commission's Annual Report on Quality and Safety 2007 found that inadequate communication between healthcare providers, or between providers and the patient and family members, was the root cause of over half the serious adverse events in accredited hospitals. Other leading causes included inadequate assessment of the patient's condition, and poor leadership or training.
Competency, education, and training.
Variations in healthcare provider training &amp; experience and failure to acknowledge the prevalence and seriousness of medical errors also increase the risk. The so-called July effect occurs when new residents arrive at teaching hospitals, causing an increase in medication errors according to a study of data from 1979 to 2006.
Human factors and ergonomics.
Cognitive errors commonly encountered in medicine were initially identified by psychologists Amos Tversky and Daniel Kahneman in the early 1970s. Jerome Groopman, author of "How Doctors Think", says these are "cognitive pitfalls", biases which cloud our logic. For example, a practitioner may overvalue the first data encountered, skewing their thinking. Another example may be where the practitioner recalls a recent or dramatic case that quickly comes to mind, coloring the practitioner's judgement. Another pitfall is where stereotypes may prejudice thinking. Pat Croskerry describes clinical reasoning as an interplay between intuitive, subconscious thought (System 1) and deliberate, conscious rational consideration (System 2). In this framework, many cognitive errors reflect over-reliance on System 1 processing, although cognitive errors may also sometimes involve System 2.
Sleep deprivation has also been cited as a contributing factor in medical errors. One study found that being awake for over 24 hours caused medical interns to double or triple the number of preventable medical errors, including those that resulted in injury or death. The risk of car crash after these shifts increased by 168%, and the risk of near miss by 460%. Interns admitted falling asleep during lectures, during rounds, and even during surgeries. Night shifts are associated with worse surgeon performance during laparoscopic surgeries.
Practitioner risk factors include fatigue,
depression, and burnout.
Factors related to the clinical setting include diverse patients, unfamiliar settings, time pressures, and increased patient-to-nurse staffing ratio increases.
Drug names that look alike or sound alike are also a problem.
Errors in interpreting medical images are often perceptual instead of "fact-based"; these errors are often caused by failures of attention or vision. For example, visual illusions can cause radiologists to misperceive images.
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