Articles: Medical Errors
Errors in Healthcare: Scope of the Problem
 Study
after study has found that the current practice of healthcare
falls far short of quality benchmarks. The cost of failing
to meet these benchmarks is enormous, whether calculated
in terms of unnecessary mortality (death), unnecessary morbidity
(illness), reduction in health-related quality of life,
or economic costs (Matchar and Samsa, 1999). The legal system
adds to the financial consequences of errors through settlements,
jury verdicts and litigation fees.
Just one type of error, medication
errors, has been reported to affect about 2 million
hospital patients a year, with some research indicating
that nearly 30 percent of mistakes are preventable. Other
researchers estimate that 3 million such mistakes occur
every year. It is estimated that 20 to 35 percent of the
healthcare organization’s bottom line goes directly
to rework and/or is lost in error (Pinkerton, 1999).
Two large studies of adverse
events took place in the early 1990’s, one conducted
in Colorado and Utah and the other in New York. The studies
found that adverse events occurred in 2.9 percent and 3.7
percent of hospitalizations, respectively. In Colorado and
Utah hospitals, 8 percent of adverse events led to death
as compared with 13.6 percent in New York hospitals. In
both of these studies, over half of these adverse events
resulted from preventable medical errors. When these statistics
are extrapolated to the over 33.6 million admissions to
United States hospitals in 1997, the results of the study
in Colorado and Utah imply that at least 44,000 Americans
die each year as a result of medical errors. Using the New
York study data suggests that the number may be 98,000 (Kohn,
Corrigan and Donaldson, 1999). Dr. Lucian Leape, one of
the principle investigators in the New York study, believes
that as many as 120,000 Americans die each year from hospital
errors.
The hidden problem revealed
While the data
regarding errors are not new, what is new is the dissemination
of this information to the public. The 1999 publication
of the conclusions of the Institute of Medicine, in the
form of a book called "To Err is Human", raised
the visibility of the problem of errors in healthcare. Their
key recommendations were:
1. Establish a national focus
to create leadership, research, tools and protocols to
enhance the knowledge base about safety.
2. Identify and learn from
errors through the immediate and strong mandatory reporting
efforts, as well as the encouragement of voluntary efforts,
both with the aim of making sure the system continues
to be made safer for patients.
3. Raise standards and expectations
for improvements in safety through the actions of oversight
organizations, group purchasers, and professional groups.
4. Create safety systems
inside health care organizations through the implementation
of safe practices at the delivery level. This level is
the ultimate target of all the recommendations (Kohn,
Corrigan and Donaldson, 1999,
p. 5).
Other recommendations included:
1. Create a National Center
for Patient Safety that would set national safety goals,
track programs, fund research on error rates, and prevention
strategies, and serve as a clearinghouse of educational
information and best practices.
2. Peer review protections
should be extended to cover voluntary reporting of near
misses or errors that do not have serious consequences.
3. Groups that license and
certify physicians and other health care providers should
implement periodic reexaminations to document both practitioners’
competence and knowledge of safety practices. Other regulators
should make patient safety a key component of evaluations.
4. Hospitals and other healthcare
organizations should implement established medication
safety practices and other methods known to reduce errors
(Prager, 1999).
The Institute of Medicine report
concluded that errors in medicine occurred within the complex
system of healthcare. Complex problems demand multiple,
multifaceted solutions. There is a lot to be done to make
the healthcare system safer. This study can be downloaded
or ordered as a book from www.nap.edu. It is essential reading for trial
attorneys handling medical malpractice cases.
"To Err is Human"
focused in part on medication errors. These have been reported
to affect about 2 million hospital patients a year, causing
7000 deaths per year. A recent study by the Pediatric Pharmacy
Advocacy Group and the Institute for Safe Medication Practices,
elicited responses from 312 people. The findings revealed
that there were significant gaps in full implementation
of even the most prevalent safety practices. Among their
findings, as reported by Gibbons (2000):
1. Specialized
training for pharmacy staff who prepare pediatric intravenous
solutions was dangerously inconsistent.
2. Only
half of the respondents reported that the patient’s
weight was always entered into the computer before processing
orders to allow the system to warn practitioners about
drug doses that exceed safe limits.
3. Three-quarters
of all respondents said that prescribers inconsistently
or never list the mg/kg dose with pediatric drug orders.
Only half of the neonatal intensive care unit or pediatric
intensive care unit respondents reported that pharmacists
always verify the mg/kg dose and recalculate the specific
patient dose before dispensing pediatric drug orders,
regardless of the setting of case.
4. Only
80 percent of the general pediatric unit respondents reported
always entering a patient’s age before processing
a drug order
(Kohn, Corrigan and Donaldson, 1999, p. 5).
It is clear that these problems
reflect flaws in the healthcare system that allow dangerous
practices to exist. Recognition of a problem, without resultant
efforts to make the system safer, increases the facility’s
liability.
References:
Gibbons, M. (2000), Pediatric
medication errors, Advance for Nurses, Greater Philadelphia,
September 25, 2000
Kohn, L., Corrigan, J., Donaldson,
M. (Eds.) (1999). To Err is Human: Building a Safer Health
System. Institute of Medicine. Washington DC: National Academy
Press.
Matchar, D. and Samsa, G. (1999,
October). The role of evidence reports in evidence-based
medicine: a mechanism for linking scientific evidence and
practice improvement. The Journal of Healthcare Quality:
The Joint Commission Journal, 522.
Pinkerton, S. (1999, July-August).
Best nursing practices and best hospitals. Journal of Professional
Nursing, 15 (4), 207.
Prager, L. (99/12/20). Report
unleashes furious interest in medical errors. American Medical
News.
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