Continuing Education Activity
The term "medical error" encompasses a diverse group of events that vary in magnitude and their potential to harm the patient. The historical perspective of medical errors was that they were a "rare occurrence." In the past few decades, this perspective has changed drastically, and the data show that it is simply untrue. Medical errors and preventable adverse events are a global problem. The first step in improving patient safety is an intricate understanding of the various types of medical errors and the healthcare processes that lead to medical errors during healthcare delivery. This activity reviews the common types of medical errors and the current practices that have been shown to decrease the rate of medical mistakes. Implementing these practices in healthcare delivery can help reduce medical errors, improve patient outcomes, and increase patient satisfaction with the healthcare industry.
Assess the global impact of medical errors.
Recognize the common types of medical errors and risk factors that increase incidence.
Identify the clinical and system-based interventions that have been shown to decrease the incidence of medical errors.
Collaborate with the interprofessional team to reduce the impact of medical errors and improve clinical outcomes.
The term "medical error" encompasses a diverse group of events that vary in magnitude and potential to harm the patient. The historical perspective of medical errors was that they were a "rare occurrence." In the past few decades, this perspective has changed drastically. In a 1997 survey from the National Patient Safety Foundation at the American Medical Association titled "Public Opinion of Patient Safety Issues Research Findings," the general public labeled the healthcare environment as only "moderately safe" with a rating of 4.9 on a scale of 1 to 7 (where 1 was Not Safe at All, and 7 was Very Safe). The survey reported that the general public found the healthcare industry less safe than airline travel or the workplace environment.
One of the most worrisome findings from this survey was that 52% of respondents felt that the healthcare system did not have adequate measures to prevent medical errors. When asked what they perceived as the cause of "medical mistakes," the most frequent responses were "carelessness or negligence" and "overworked, hurried, or stressed" healthcare professionals.
Medical errors and preventable adverse events are not unique to the US. They are, in fact, a global problem. According to one review, an Australian-based study reported that 16.6% of all admissions had preventable adverse outcomes, resulting in death in nearly 5% of the cases with an iatrogenic injury. Similarly, a United Kingdom (UK)-based retrospective study reported an adverse event rate of 11%. Other countries have reported similar rates of adverse events, with a New Zealand-based study reporting a rate of 10.7% and a Danish study reporting a rate of 9%.
While the statistics and public opinion about the healthcare industry are disconcerting, they should not lead to despair. Understanding the magnitude of the issue and the general view of our performance is the first step in resolving the issue. This will allow us to identify common causes of medical errors and implement system-based practices that help prevent these outcomes.
The first step in improving patient safety is an intricate understanding of the various types of medical errors and the healthcare processes that lead to medical errors during healthcare delivery. This activity reviews the common types of medical errors and the current practices that have been shown to decrease the rate of medical mistakes. Implementing these practices in healthcare delivery can help reduce medical errors, improve patient outcomes, and increase patient satisfaction with the healthcare industry.
A medical error has been defined as "an unintended injury caused by medical management" that results in "measurable disability." Some experts describe an inherent flaw in this definition: it is "outcome-dependent," which is only valuable for assessing the impact of medical errors and does not provide any insight into the cause or possible preventive strategies. They suggest a "process-dependent" definition that captures the causes of medical errors, irrespective of the patient outcome. This definition would incorporate errors that do not result in injury (the so-called "near misses" or "close calls") and allow the implementation of preventive strategies that will be more effective in decreasing medical error rates.
Defining medical error as an act of "omission or commission in planning or execution that contributes or could contribute to an unintended result" encompasses all measurable adverse outcomes and "close calls" that can result from errors in planning and execution of healthcare as well as errors of commission.
According to the Institute of Medicine (IOM) Committee on Quality of Health Care in the US, an "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 IOM identifies an adverse event as an injury caused by medical management rather than the underlying condition of the patient. If the adverse event can be attributed to an error, it is classified by the IOM as a "preventable adverse event." A subset of these preventable adverse events is called "negligent adverse events," where the care provided fails to meet the standard of care and results in an adverse event.
Regardless of the definition, medical errors are associated with high morbidity and mortality and a high economic burden. Medical errors not only affect the patient, their family, and healthcare providers; they also negatively impact support staff, the healthcare facility, and the community. They have been identified as a public health problem and a "serious threat to patient safety."
Issues of Concern
The IOM identifies medical errors as a leading cause of death and injury. According to the 2019 World Health Organization (WHO) Patient Safety Factsheet, adverse events due to unsafe patient care are among the top ten causes of death and disability worldwide. Preventable adverse events in the United States of America (US) cause an estimated 44,000 to 98,000 deaths in hospitals each year. This exceeds the number of deaths attributable to motor vehicle accidents and is estimated to cost the community between 37.6 to 50 billion dollars in terms of added health care cost, disability, and loss of productivity.
Patients and their families face the most critical and severe consequences of medical errors. Therefore, identifying system processes that lead to medical errors and implementing corrective measures is the primary goal in treating this problem.
Types of Medical Errors
- Medication error is widely accepted as the most common and preventable cause of patient injury. Medication errors include giving the wrong drug or dose, via the wrong route, at an incorrect time, or to the wrong patient. The reported incidence of medication error-associated adverse events in acute hospitals is around 6.5 per 100 admissions. Medication errors occurring in the peri-discharge period from an acute care facility are the most easily overlooked or missed errors.
- Another common medical error is a diagnostic error with failure to correctly identify the cause of the clinical condition in a timely manner. Diagnostic errors have been defined as "missed opportunities to make a correct or timely diagnosis based on the available evidence, regardless of patient harm."
- In hospitalized patients, wound infections, pressure ulcers, falls, healthcare-associated infections, and technical complications constitute another group of preventable medical errors.
- The most common systems-error is failure to disseminate drug knowledge and patient information. This, in essence, is a communication failure, whether with the patient or other providers.
- Failure to employ indicated tests is another medical error that can lead to diagnostic delays or errors.
- Similarly, using outdated tests or treatments or failing to respond to the results of tests or monitoring also constitutes a type of medical error.
- Treatment errors include errors during the performance of a test or procedure and inappropriate treatment.
Risk Factors that Increase the Incidence of Medical Errors
Some conditions and patient situations increase the risk of severe or fatal adverse events. For example, advanced patient age has been associated with an increased risk of adverse events related to medical errors. However, the most significant risk factor for medical errors and associated adverse events is "human error." Conditions that increase the risk of human error in the healthcare industry include:
- Schedule instability
- Sleep Deprivation
- Rotating shiftwork that leads to sleep disturbances and, in many cases, chronic sleep deprivation has been linked to poor work performance, increased sick leave utilization, and a higher likelihood of work-related accidents/errors.
- Provider burnout
- Physician or provider burnout is estimated to affect 50% of all practicing providers. This, in turn, affects provider productivity and has been associated with an increased risk of major medical errors.
- Workload and nurse-to-patient ratio
It is essential to understand that healthcare delivery involves multiple variables in a dynamic environment, with many critical decisions made in a short amount of time, especially in an emergency department or critical care setting. As such, the healthcare system cannot implement the strict operations processes used by other high-risk industries, such as the aviation industry. Therefore, reducing medical errors requires a multifaceted approach at various levels of healthcare, as outlined below.
Encourage Error Reporting
An essential first step is encouraging medical error reporting so that adverse events and "close calls" may be highlighted as often as they occur. All healthcare facilities must address any barriers to medical error reporting to optimize patient safety. The most common barrier to medical error reporting is a fear of consequences. Changing workplace culture and strategies for addressing medical errors can help decrease this fear and encourage medical error reporting. Adopting a patient safety culture, where providers are empowered and rewarded for identifying medical errors that could lead to patient harm, has been shown to overcome the fear of consequences.
Another identified barrier to medical error reporting is a lack of proper understanding of what constitutes a medical error. This frequently leads to underreporting due to a lack of provider understanding of the clinical situation. Robust, periodic, and continuous provider education regarding what constitutes a medical error, how to report it, and what can be the expected consequences will help in better identification of potential medical errors.
Implement Legislative Measures to Promote Patient Safety
The IOM gave the following recommendations to help reduce the incidence of medical errors at the legislative level:
- Public health agencies should set national goals for patient safety, track progress, and issue an annual report on patient safety.
- Performance standards for healthcare organizations should focus on patient safety.
- Health professional licensing bodies should periodically evaluate providers on clinical competence and knowledge of safety practices.
Implement Strategies to Prevent Medication Errors
According to a recent Cochrane Review, interventions can decrease the frequency of medication errors in acute hospital settings. Some of these interventions include:
- Medication reconciliation at the time of hospital admission and discharge
- Computerized physician order entry (CPOE)
- Clinical decision support systems (CDSS)
- Barcode identification of patients and the medications being administered
- Reduced working hours for clinical providers and nurses
A recent study from Portugal reported that the use of electronic medical records not only reduced medication errors but also "contributed to a continuous improvement in patients' safety." Another study noted that prescribing errors were greatly reduced with the use of computerized medication reconciliation and pharmacist-led medication reconciliations.
However, the single most effective method for reducing medication errors is using CPOE systems. CPOE systems replaced paper-based ordering systems, allowing clinicians to maintain an online medication administration record with real-time reviews of modifications made to orders by other providers and personnel.
Improve Communication and Patient Hand-off
Using standardized communication tools such as SBAR (situation briefing model) can improve team collaboration and reduce medical errors, especially in hospital settings. SBAR stands for situation, background, assessment, and recommendation. SBAR and its various derivatives are used as a communication and hand-off tool intra-professionally and inter-professionally to convey pertinent patient information in an organized and logical fashion. The SBAR tool is considered a 'best practice' communication technique to deliver information in hand-off and critical patient care situations.
The National Academies of Sciences, Engineering, and Medicine of the US require a standardized approach to "hand off" communications, especially at training institutions, to avoid medical errors when continuity of care is interrupted. They also recommend that these hand-offs occur in real-time and allow the opportunity to ask and respond to questions regarding pertinent facts about patient care.
Communication with families is another essential part of medical communication that should be implemented, especially in the care of pediatric populations. According to a recent study, implementing standardized healthcare provider-family communication at the patient bedside using "family-centered rounds" with family engagement and bidirectional communication decreased the frequency of harmful medical errors and positively impacted the family experience.
Reduce Diagnostic Errors
Reducing diagnostic errors requires a more comprehensive approach. It requires system-based safety checks and algorithms such as "trigger tools" and clinician feedback or counseling.
According to a New England Journal of Medicine article from 2015, "trigger tools" are essential in reducing this type of medical error. "Trigger tools" are electronic algorithms that identify potential adverse events. This is accomplished by searching electronic health records and flagging specific occurrences. The use of trigger tools has been shown to decrease the rate of misdiagnoses in recent studies.
Another critical tool in reducing diagnostic errors is developing validated metrics for diagnostic errors. Identifying the error and root cause of the event can then be used to provide effective provider feedback and help build system safety checks to prevent such errors in the future.
Clinicians should be encouraged to employ strategies to reduce their risk of diagnostic mistakes. Fostering critical thinking and promoting a "pause and reflect" strategy can help avert diagnostic errors, especially in cases with obscure clinical findings or unexpected clinical trajectories. A recent study from Japan identified cognitive factors such as faulty clinical perception, cognitive biases, and "failed heuristics" as causative factors in most malpractice claims associated with diagnostic errors.
Aside from encouraging critical thinking, opportunities for case discussions and second opinions should be made available for the treating providers. Healthcare facilities should also provide avenues for second opinions or interdisciplinary teams where cases can be discussed.
Reducing Procedural Errors and Surgical Complications
Implementing checklists, such as the World Health Organization Surgical Safety Checklist (WHO SSC), has been shown to reduce procedural complications on a global scale. It positively impacted safety process measures such as objective airway evaluation, prophylactic antibiotic use, confirmation of patient identity and site of the procedure, and sponge counts post-procedure. Implementing a surgical checklist has also been shown to reduce surgical complication rates, wound infections, blood loss, and mortality rates. The WHO SSC is universally recommended to prevent surgical site infections, ensure safer anesthesia, and reduce perioperative mortality.
Prevent Patient Falls
Patient factors contributing to falls include advanced age, mobility impairment, and surgery. Organizational factors contributing to falls include nurse staffing and the proportion of new nurses. Instuting fall prevention protocols in hospitals and long-term care facilities have had a major impact in reducing these errors. Studies have shown that fall risk assessments using standardized scales such as the Morse fall scale can decrease patient falls. Institutional interventions such as staff education, patient mobility training with rehabilitation professionals, and nutritionist support have also been shown to reduce patient falls.
Prevent Healthcare-associated Infections
The most common healthcare-associated infections include:
- Catheter-Associated Urinary Tract Infections (CAUTI)
- Surgical Site Infections (SSI)
- Hospital-Acquired Pneumonia (HAP) and Ventilator-Associated Pneumonia (VAP)
- Central Line-Associated Bloodstream Infections (CLABSI)
- Care-related Skin and Soft Tissue Infections (SSTI)
Hand-hygiene campaigns have been shown to decrease the number of nosocomial infection rates for various infections and should be universally endorsed. Most healthcare facilities now employ specific protocols for minimizing central venous and urinary catheter use and using protective measures such as chlorhexidine for vascular catheter site care to reduce the incidence of healthcare-associated bloodstream infections, ventilator-associated pneumonia, and catheter-associated urinary tract infections. Minimizing the duration of use for these indwelling catheters is cited as one of the most effective measures in reducing the incidence of these infections.
Pharmacy-driven antibiotic stewardship programs should be regularly employed in all patients admitted to a healthcare facility to decrease the risk of nosocomial Clostridioides infections and the risk of recurrent Clostridioides infections. Frequent skin assessment and evaluation by wound care teams with regular and focused nursing education and evidence-based treatments should be routinely employed as it has been shown to lower healthcare-associated pressure injuries. The care of surgical sites should follow similar protocols, with some studies proposing the use of chlorhexidine-impregnated dressings to decrease the incidence of surgical site infections.
Reduce Provider Burnout
Provider burnout is directly associated with an increased risk of self-reported medical errors. Physician burnout, in particular, has also been associated with an increased risk of unsolicited patient complaints. Addressing provider burnout by reducing work hours and implementing other activities can decrease this risk. The current recommendation is to limit workweeks, especially for trainees, to an average of 80 hours over four weeks, with the longest consecutive work period limited to 30 hours. This can prevent acute and chronic sleep deprivation among clinicians and minimize the risk of fatigue-related medical errors.
It is imperative to understand that burnout is a systems issue, not an individual disease. Physicians generally cite the pervasive use of electronic medical records (EMR) and time spent on "clerical" nonclinical duties as the cause of burnout. These tasks include documenting patient encounters, explaining the need for a particular drug or test to insurance companies, and responding to a billing query.
Using scribes has been suggested as an effective way of decreasing "provider interaction with the EMR." However, the impact of scribes on medical error rates and physician burnout has not been directly studied. In the primary care setting, using scribes has been shown to decrease EMR documentation time and increase physician satisfaction.
A position paper by the American College of Physicians (ACP) put forth recommendations to help reduce the time spent by physicians on administrative tasks and decrease physician burnout. These recommendations include:
- Provide financial, time, and quality-of-care impact statements for administrative tasks assigned to physicians.
- Conduct a thorough review of these statements.
- Tasks that are determined to have a negative effect on the quality of patient care, that unnecessarily question provider judgment, and that unnecessarily increase the cost of clinical care should be challenged, revised, or removed entirely.
Medical Error Disclosure
Of paramount importance in dealing with medical errors is complete and timely disclosure of a medical error once it is known to have occurred. Communication regarding its occurrence should be made in a timely manner to the patient and their family. This helps demonstrate respect, compassion, and commitment to quality care and patient safety by the healthcare team. The disclosure should provide information regarding the event, acknowledge the harm incurred, and explain the steps that will be taken to mitigate the harm if at all possible. It should also allow the patient and family members to ask questions.
Disclosure of medical errors should also include disclosure to regulatory agencies and institutional committees so that organizational changes that can prevent such errors in the future may be implemented. Patient-safety incidents should be reported and reviewed for use in improving system-based practices to promote patient safety. Care must be taken in this regard to avoid individual blame.
Impact of Punitive Measures Following a Medical Error
The criminalization of medical errors should be avoided and is seen by the Anesthesia Patient Safety Foundation (APSF) of the US as counterproductive. In a position statement by the APSF published in October 2022, the foundation called for improvement in systems of care as opposed to the criminal prosecution of individuals involved.
Clinical providers experience various negative emotions after a medical error, including anxiety, depression, and fear. Individual blame increases the severity of these symptoms and leads to poor emotional well-being, which can further hinder clinical performance. Medical literature proposes counseling the individual involved and focusing on the system that allowed the mistake to occur. This is the optimal solution as it mitigates the adverse effects on clinical providers while addressing patient safety.
The recent case of the State of Tennessee vs. Radonda L. Vaught brought forth many deficiencies in the healthcare system that led to the death of an elderly patient who would otherwise have been discharged home. However, the criminalization of the particular individual resulted in many healthcare professionals voicing fear of similar consequences for themselves. In response to this trial, the Washington State Nurses Association issued the following statement: "Focusing on blame and punishment solves nothing. It can only discourage reporting and drive errors underground. It not only undermines patient safety; it fosters an environment of fear and lack of respect for healthcare workers."
A direct result of the criminalization of medical errors is the rise of defensive medicine at the provider level and delayed medical care at the nursing level. Healthcare professionals are identified as "second victims" of medical errors after the patient and their family. The fear of mistakes and litigation has raised the practice of defensive medicine to everyday practice. Defensive medicine is unethical and increases the financial burden of healthcare on the community. Punitive measures, such as those highlighted above, continue to encourage the practice of defensive medicine and should, therefore, be avoided. Many nurses responding to the specifics of State vs. Vaught said they would no longer "override" the medication dispensing cabinet regardless of the patient care situation. The American Nurses Association stated, "The criminalization of medical errors will not preserve safe patient care environments."
Enhancing Healthcare Team Outcomes
Medical errors are a significant concern for patient safety in the healthcare industry. Healthcare professionals and policymakers can reduce the burden of medical errors on patients and clinical providers by focusing on clinical education and implementing healthcare systems that deter "easy mistakes." It is essential to recognize that faulty or inadequate knowledge is not a common cause of medical errors. Unintentional medical errors will likely always occur. However, the risk of medical errors may be significantly reduced by focusing efforts on constructive environments, standardized communication systems, electronic data and order entry, medication reconciliations, and error prevention clinical care protocols.[Level 5]
Clinical nurses and pharmacists can help prevent medication errors by helping the providers obtain an accurate medication reconciliation on admission and discharge from a medical facility. The clinical nurse also plays a vital role in preventing healthcare-associated infections, pressure ulcers, and falls. The clinical nurse is also tasked with patient monitoring and effective communication with the providers to ensure all critical information points are conveyed concisely to help minimize errors in clinical decision-making.
Accreditation agencies and training programs must focus on medical errors as an inherent part of human medical practice and teach ways to minimize such errors. A collaborative interprofessional team of clinicians, nurses, pharmacists, and education specialists can greatly reduce the incidence of medical errors in the healthcare industry.[Level 5]
Nursing, Allied Health, and Interprofessional Team Interventions
To effectively decrease medical error rates and keep their patients safe, healthcare organizations, particularly hospitals and long-term care facilities, must restructure nursing work environments. Inadequate working environments, excess duty hours, and high workloads can lead to missed nursing care and an increased risk of adverse events.
According to the Institute of Medicine (IOM), fatigue during shift work increases error rates and must be addressed to improve patient safety. They propose the following recommendations to combat nursing fatigue during shift work:
- Clockwise shift rotations (i.e., from day to evening to night) rather than in the reverse order.
- Avoid scheduling prolonged periods of wakefulness. The report notes that extending shift hours to result in 17 hours or more of prolonged wakefulness can negatively impact task performance, equivalent to the legal limit of alcohol intoxication.
- Avoid scheduling more than four consecutive 12-hour shifts.
- Avoid short off-duty periods. Off-duty periods of 8 hours or less will result in excessive fatigue during the following shift.
- Avoid extending duty hours beyond what was scheduled for the day.
According to the IOM report, these interventions should guide scheduling and are not absolute cut-offs for working hours. Their report noted that the overall error rate by nurses was around 0.00336 errors per hours-worked; however, working overtime, working longer than scheduled on a given day, and working extra shifts did not result in any significant increase in this error rate unless the shift durations exceeded 12 consecutive hours. When shift durations exceeded 12 hours, a substantial increase in error rate was noted even if the shift was voluntarily scheduled.
Noting this data, the IOM calls for legislative and regulatory bodies to prohibit nursing staff from providing patient care in excess of 12 hours in any given 24-hour period under any circumstance. The IOM also recommends limiting nursing work hours to 60 per 7-day period for nurses who provide direct patient care.
Other interventions recommended by the IOM focus on establishing a work environment that allows easy monitoring of patients, limits interruptions, and minimizes clerical tasks. Special education and training should be provided for error-prone tasks such as medication administration, patient hand-off, and supervising trainees. The latter is particularly important to promote an ongoing culture of patient safety and error-free medication administration. A recent study from Ghana surveying nursing students regarding their perception of medical errors committed during direct patient care reported that "less knowledge" about the task or procedure and "lack of supervision" was the primary cause of medical errors they committed during training.
An overall commitment to patient safety at the organizational level greatly influences nurses' adherence to and compliance with patient-safety principles. Creating an organizational patient-safety climate, managing workload, reducing time pressure, and providing education for improving knowledge and skills enhances their adherence to patient-safety principles.
Close monitoring for missed nursing care and nurse fatigue should follow the implementation of patient safety interventions. Nonpunitive, focused, and effective feedback can improve patient safety adherence and clinical outcomes.
Focused emphasis should be given to individuals who require personal motivation, resist change, or are averse to innovation. These individuals need empowerment and a nonjudgmental approach in their training toward patient-safety practices. Improving knowledge regarding patient care tasks and the breadth of medical errors that can be prevented with adherence to patient-safety principles has been shown to enhance their commitment to patient safety.
An essential step in transforming nurse work environments to promote patient safety is to involve the patient and their families. Patients are critical players in ensuring safe patient care occurs. Engaging patients in safe-care initiatives compliment patient-safety principles and should be employed as much as possible. This can be accomplished by educating the patient regarding care initiatives and planning and performing nursing care at their bedside.