Medical errors are considered as the unintended actions or the ones that fail to achieve their expected outcomes. Patient harm due to medical errors can be at various levels such as individual or system level. Moreover, they can occur at different stages during a treatment such as a diagnosis, medication management, treatment, shared decision-making, communication and other human or technical errors. A sentinel event is defined as an unexpected turn of events that cause death, physical and psychological wounds or any other complicated adverse outcomes. Such events call for an immediate investigation about the diagnosis of cause and response upon the indication ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"oS5cuwPp","properties":{"formattedCitation":"(Rodziewicz & Hipskind, 2019)","plainCitation":"(Rodziewicz & Hipskind, 2019)","noteIndex":0},"citationItems":[{"id":672,"uris":["http://zotero.org/users/local/OnfrXiA2/items/6AR7TEQD"],"uri":["http://zotero.org/users/local/OnfrXiA2/items/6AR7TEQD"],"itemData":{"id":672,"type":"chapter","title":"Medical Error Prevention","container-title":"StatPearls","publisher":"StatPearls Publishing","publisher-place":"Treasure Island (FL)","source":"PubMed","event-place":"Treasure Island (FL)","abstract":"Medical errors are a serious public health problem and a leading cause of death in the United States. It is a difficult problem as it is challenging to uncover a consistent cause of errors and, even if found, to provide a consistent viable solution that minimizes the chances of a recurrent event. By recognizing untoward events occur, learning from them, and working toward preventing them, patient safety can be improved [1]. Part of the solution is to maintain a culture that works toward recognizing safety challenges and implementing viable solutions rather than harboring a culture of blame, shame, and punishment. Healthcare organizations need to establish a culture of safety that focuses on system improvement by viewing medical errors as challenges that must be overcome. All individuals on the healthcare team must play a role in making the provision of healthcare safer for patients and healthcare workers [2]. All providers know medical errors create a serious public health problem that poses a substantial threat to patient safety. Yet, one of the most challenging unanswered questions is \"What constitutes a medical error?\" The answer to this basic question has not been clearly established. Due to unclear definitions, “medical errors” are difficult to scientifically measure. A lack of standardized nomenclature and overlapping definitions of medical errors has hindered data analysis, synthesis, and evaluation. There are two major types of errors: 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. Health care professionals experience profound psychological effects such as anger, guilt, inadequacy, depression, and suicide due to real or perceived errors. The threat of impending legal action may compound these feelings. This can also lead to a loss of clinical confidence. Clinicians equate errors with failure, with a breach of public trust, and with harming patients despite their mandate to “first do no harm.” Fear of punishment makes healthcare professionals reluctant to report errors. While they fear for patients’ safety, they also dread disciplinary action, including the fear of losing their jobs if they report an incident. Unfortunately, failing to report contributes to the likelihood of serious patient harm. Many healthcare institutions have rigid policies in place which also create an adversarial environment. This can cause staff to hesitate to report an error, minimize the problem, or even fail to document the issue. These actions or lack thereof can contribute to an evolving cycle of medical errors. When these errors come to light, they can tarnish the reputation of the healthcare institution and the workers [3]. Some experts hold that the term “error” is excessively negative, antagonistic and perpetuates a culture of blame. A professional whose confidence and morale has been damaged as a result of an error may work less effectively and may abandon a career in medicine. Many experts suggest the term “error” should not be used at all. Due to the negative connotation, it is prudent to limit the use of the term “error” when documenting in the public medical record. However, adverse patient outcomes may occur because of errors; to delete the term obscures the goal of preventing and managing its causes and effects [4]. Errors, no matter the nomenclature, typically occur from the convergence of multiple contributing factors. Public and legislative intolerance for medical errors typically illustrates a lack of understanding that some errors may, in fact, not be preventable with current technology or the resources available to the practitioner. Human factors are always a problem, and identifying errors permits improvement strategies to be undertaken. In particular, blaming or punishing individuals for errors due to systemic causes does not address the causes nor prevent a repetition of the error. The trend is for patient-safety experts to focus on improving the safety of health care systems to reduce the probability of errors and mitigate their effects, rather than focus on an individual’s actions. Errors represent an opportunity for constructive changes and improved education in health care delivery. Governmental, legal, and medical institutions must work collaboratively to remove the culture of blame while retaining accountability. When this challenge is met, health care institutions will not be constrained from measuring targets for process improvement, including all errors, even with adverse outcomes. Healthcare providers want to improve outcomes while reducing the risk of patient harm. Despite provider best efforts, medical error rates remain high with significant disability and death. Preventable medical errors contribute substantially to healthcare cost, including higher health insurance costs per person expenses. Only by health professionals working together will the cost and injury associated with medical errors be mitigated. The Joint Commission Patient Safety Goals The Joint Commission has introduced several patient safety goals to assist institutions and healthcare practitioners in creating a safer practice environment for patients and providers [5]. The Joint Commission Goals include: Identify patient safety dangers and risks. Identify patients correctly by confirming the identity in at least two ways. Improve communication such as getting test results to the correct person quickly. Prevent infection by hand-cleaning, post-op infection antibiotics, catheter changes, and central lines precautions. Prevent mistakes in surgery by making sure the correct surgery is done on the correct body part; pause before surgery to double check. Use device alarms and make sure that alarms on medical equipment are heard and checked quickly. Use medicines correctly and safely, double checking labeling and correctly passing on patient medicines to the next provider. Label all medications, even those in a syringe. This should preferably be done in the area where the medications are prepared. Take extra time with patients who have been prescribed anticoagulants and chemotherapeutic agents. To prevent nosocomial infections, hand washing should be routine before and after visiting each patient. Accountability While it is true that individual providers should be held accountable for their decisions, there is a growing realization that the majority of errors are out of the clinician's control [6]. This being said, it remains difficult to change a culture of non-reporting. Questions to consider include: The potential for errors in healthcare is very high. Due to cost control measures, are individuals accountable, or is increased workload and staff fatigue the reason for errors? Why report? Failure to report errors may subject clinicians to disciplinary action and increased risk for legal liability. Beneficence and nonmaleficence are ethical concepts that are violated when an error is not reported. Practitioners often fear they will gain a reputation for committing mistakes and may not self-report. They know that mistakes and written warnings are often recorded in personnel files. Does the system need modification to decrease the penalty and encourage reporting? Punishment may, in fact, reduce reporting errors because of the discipline and humiliation that is associated with repeated errors. Nevertheless, not addressing the problem increases the potential for more adverse events which places more patients at risk. Rather than placing blame, administrators and review boards need to move toward eliminating the blame-shame-discipline structure and move toward a prevention and education structure. This culture incorporates both learning and improvement efforts that target system redesign and a reporting culture whereby all providers feel safe from retribution and, therefore, report issues about safety that help to constantly improve patient care and improve the safety of the system. Definitions Patient safety has typically been outcome-dependent and the focus has been on preventing patients from experiencing adverse outcomes when receiving medical care. This may stem from Hippocrates, primum no nocere, or “First, do no harm.” While definitions in the literature are unclear, some general concepts can be garnered. Multiple similar definitions are available for each of these terms from various sources; the health practitioner should be aware of the general principles and probable meaning [7];[8]. \n Active Error\n : Active errors are those taking place between a person and an aspect of a larger system at the point of contact. Active errors are made by people on the front line such as clinicians and nurses. For example, operating on the wrong eye or amputating the wrong leg are classic examples of an active error. \n Adverse Event\n Adverse events may be preventable when there is a failure to follow accepted practice at a system or individual level. An adverse event attributable to an error usually is a preventable adverse event. An adverse event is a type of injury that most frequently is due to an error in medical or surgical treatment rather than the underlying medical condition of the patient. Not all adverse outcomes are the result of an error; hence, only preventable adverse events are attributed to medical error. An unintended injury is medical or surgical patient management that results in prolonged hospitalization, measurable physical disability, or both. An unintended injury or complication is the result of prolonged hospitalization or disability or is caused by factors inherent in the healthcare system rather than a disease. \n Latent Error\n : These are errors in system or process design, faulty installation or maintenance of equipment, or ineffective organizational structure. These are present, but may go unnoticed for a long time with no ill effect. When a latent error occurs in combination with an active human error, some type of event manifests in the patient. The active human error triggers the hidden latent error, resulting in an adverse event. Latent errors are basically \"accidents waiting to happen.\" A classic example is a hospital with several types of chest drainage sets, all requiring different connections and setups, yet not all frontline clinicians and nurses are familiar with the intricacies of each setup, creating the scenario for potential error. \n Medical Error\n : The failure to complete the intended plan of action or implementing the wrong plan to achieve an aim. An unintended act or one that fails to achieve the intended outcome. Deviations from the process of care, which may or may not result in harm. When planning or executing a procedure, the act of omission or commission that contributes or may contribute to an unintended consequence. \n Negligence\n Failure to meet the reasonably expected standard of care of an average, qualified healthcare worker looking after a patient in question within similar circumstances. For example, the healthcare worker may not check up on the pathology report which led to a missed cancer or the surgeon may have injured a nerve by mistaking it for an artery. \n Negligent Adverse Events\n : A subcategory of preventable, adverse events that satisfy the legal criteria used in determining negligence. The injury caused by substandard medical management. \n Near Miss\n : Any event that could have had an adverse patient consequence but did not. Potential adverse events that could have caused harm but did not, either by chance or because someone or something intervened. Near misses provide opportunities for developing preventive strategies and actions and should receive the same level of scrutiny as adverse events. \n Never Event\n Never events are errors that should not ever have happened. A classic example of a never event is the development of pressure ulcers or wrong-site surgery. The National Quality Forum has identified the following as Serious Reportable Events: Care Management. Device/Product. Environmental. Patient Protective. Surgical. Radiological. \n Noxious Episode\n Untoward events, complications, and mishaps that result from acceptable diagnostic or therapeutic measures deliberately instituted. For example, sending a hemodynamically unstable trauma patient for prolonged imaging studies instead of the operating room. The result could be a traumatic arrest and death. \n Patient Safety\n The process of amelioration, avoidance, and prevention of adverse injuries or outcomes that arise as a result of the healthcare process. \n Potentially Compensable Event\n : An error that could potentially lead to malpractice claims. An event due to medical management that resulted in disability, and, subsequently, a prolonged hospitalization. \n Root Cause\n A deficiency or decision that, if corrected or avoided, will eliminate the undesirable consequence [9]. Common root causes include: Changes in mental acumen including conducting healthcare in an automatic fashion, not seeking advice from peers, misapplying expertise, not formulating a plan, or not considering the most obvious diagnosis. Communication issues, having no insight into the hierarchy, having no solid leadership, not knowing whom to report the problem, failing to disclose the issues, or having a disjointed system with no problem-solving ability. Deficiencies in education, training, orientation, and experience. Inadequate methods of identifying patients, incomplete assessment on admission, failing to obtain consent, and failing to provide education to patients. Inadequate policies to guide healthcare workers. Lack of consistency in procedures. Inadequate staffing and/or poor supervision. Technical failures associated with medical equipment. No audits in the system. No one prepared to accept blame or change the system. \n Sentinel Event\n The Joint Commission defines a \"sentinel event\" as “any unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof...The phrase 'or the risk thereof' includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.” (The Joint Commission, 2017). Sentinel events are so called because, once discovered, they frequently indicate the need for an immediate investigation, discovery of cause, and response. Extent of the Challenge Approximately 400,000 hospitalized patients each year experience some type of preventable harm [10]. Depending on the study, medical errors account for over $4 billion per year. Medical errors cost approximately $20 billion a year. Medical errors in hospitals and clinics result in approximately 100,000 people dying each year. Medical errors typically include surgical, diagnostic, medication, devices and equipment, and systems failures, infections, falls, and healthcare technology. Missed diagnoses or injuries from medication are common in outpatient settings. Most malpractice claims in hospitals are related to surgical errors, whereas most claims for outpatient care are related to missed or late diagnosis. Slightly more than half of the paid malpractice claims are related to outpatient care. To decrease overhead, hospitals often reduce nursing staff; staffing of RNs below target levels is associated with increased mortality.","URL":"http://www.ncbi.nlm.nih.gov/books/NBK499956/","call-number":"NBK499956","note":"PMID: 29763131","language":"eng","author":[{"family":"Rodziewicz","given":"Thomas L."},{"family":"Hipskind","given":"John E."}],"issued":{"date-parts":[["2019"]]},"accessed":{"date-parts":[["2019",11,16]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Rodziewicz & Hipskind, 2019). The medical errors can be prevented by ensuring every measure for patient safety. It includes the improvement in the current medical procedures, prevention and evasion of adverse outcomes that might arise due to errors in the health care process.
Several practices that can be ensured in the mediation process includes prescription, and labelling of medicine correctly and double-checking before passing it on to the patients. All medications should be labelled properly either syringes, drugs, tablets, or chemicals. Human errors are always considered as an unavoidable problem in the health care process. In order to bring improvement in treatment and care strategies, it is important to identify all these errors. Errors present an opportunity to bring constructive changes and improvement in health care education. The collaboration among different health care professionals and better communication and flow of information regarding patient’s case can prevent medical errors. Medical errors in pediatric care can be prevented by reducing diagnostic and medication errors. The electronic health care records are also a cause of medical errors including mistakes in prescription and can be removed by taking out time to double-check and confirm ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ijVhP3yG","properties":{"formattedCitation":"(Daniel R Neuspiel, 2018)","plainCitation":"(Daniel R Neuspiel, 2018)","noteIndex":0},"citationItems":[{"id":670,"uris":["http://zotero.org/users/local/OnfrXiA2/items/LNWGYYCH"],"uri":["http://zotero.org/users/local/OnfrXiA2/items/LNWGYYCH"],"itemData":{"id":670,"type":"webpage","title":"Prevent medical errors in your practice","container-title":"Contemporary Pediatrics","abstract":"Diagnostic and medication errors frequently occur in pediatric practices, but even minor medical errors can be prevented by creating a culture of safety.","URL":"https://www.contemporarypediatrics.com/article/prevent-medical-errors-your-practice","language":"en","author":[{"family":"Daniel R Neuspiel","given":"M. D."}],"issued":{"date-parts":[["2018",7,1]]},"accessed":{"date-parts":[["2019",11,16]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Daniel R Neuspiel, 2018). It is imperative to identify the root cause of medical errors and direct the preventive measurements towards that way.
References
ADDIN ZOTERO_BIBL {"uncited":[],"omitted":[],"custom":[]} CSL_BIBLIOGRAPHY Daniel R Neuspiel, M. D. (2018, July 1). Prevent medical errors in your practice. Retrieved November 16, 2019, from Contemporary Pediatrics website: https://www.contemporarypediatrics.com/article/prevent-medical-errors-your-practice
Rodziewicz, T. L., & Hipskind, J. E. (2019). Medical Error Prevention. In StatPearls. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK499956/
