Where Errors Occur
Errors occur not only in
hospitals but in other healthcare settings, such as physicians' offices,
nursing homes, pharmacies, urgent care centers, and care delivered in the home.
Unfortunately, very little data exist on the extent of the problem outside of
Medical errors happen when something that was planned as a part of medical care doesn't work out properly, or when the wrong plan was used in the first place. Medical errors can occur anywhere in the healthcare system:
- Outpatient Surgery Centers
- Doctors' Offices.
- Nursing Homes
- Patients' Homes
Errors can involve:
- Lab reports
- Chart notes
They can happen during even the most routine tasks, such as when a hospital patient on a salt-free diet is given a high-salt meal.
Most errors result from problems created by today's complex healthcare system. But errors also happen when doctors and their patients have problems communicating. For example, a recent study supported by the Agency for Healthcare Research and Quality (AHRQ) found that doctors often do not help their patients make informed decisions. Uninvolved and uninformed patients are less likely to accept the doctor's choice of treatment and less likely to do what they need to do to make the treatment work.
These and other medication errors reported to the FDA may stem from poor communication, misinterpreted handwriting, drug name confusion, lack of employee knowledge, and lack of patient understanding about a drug's directions. "But it's important to recognize that such errors are due to multiple factors in a complex medical system," says Paul Seligman, M.D., director of the FDA's Office of Pharmacoepidemiology and Statistical Science. "In most cases, medication errors can't be blamed on a single person."12
Types of Errors
Video Lecture #2 – Types of Medical Errors
Most people believe that medical errors usually involve drugs, such as a patient getting the wrong prescription or dosage, or mishandled surgeries, such as amputation of the wrong limb. However, there are many types of medical errors. The following seven categories summarize types of medical errors that can occur:
- Medication Errors, such as a patient receiving the wrong drug.
- Surgical Error, such as amputating the wrong limb.
- Diagnostic Error, such as misdiagnosis leading to an incorrect choice of therapy, failure to use an indicated diagnostic test, misinterpretation of test results, and failure to act on abnormal results.
- Equipment Failure, such as defibrillators with dead batteries or intravenous pumps whose valves are easily dislodged or bumped, causing increased doses of medication over too short a period.
- Infections, such as nosocomial and post-surgical wound infections.
- Blood Transfusion-related Injuries, such as a patient receiving an incorrect blood type.
- Misinterpretation of other Medical Orders, such as failing to give a patient a salt-free meal, as ordered by a physician.
A number of the most common errors are described below.
In some instances, something as simple as poor handwriting on a prescription pad can result in a pharmacist or hospital staff member administering the wrong drug or wrong dosage of the correct drug. Drug interactions have several "filters" before getting to the patient. Both the physician and the issuing pharmacist have an obligation to validate that the prescribed medication will not have an adverse interaction with any of the other medications. Nurses have an obligation to monitor hospital patients for potential adverse drug reactions, and should be free to question if they are aware of any potential bad drug interactions with patient medication. In spite of these precautionary measures, medication errors still occur. Medication errors can cause injury, extend a patient's hospital stay, and at worst result in death.
Unfortunately, errors occur
all too often during surgery. They range from leaving sponges or instruments
inside a patient to performing the wrong surgery. Surgical errors have a number
of different sources, including fatigue, miscommunication, or outright
recklessness. Surgical errors can cause significant pain and suffering,
requiring the need for repeated follow-up surgeries, with each surgery leaving
a patient prone to infection and other risks. In the worst case scenario,
surgical errors lead to death.
Hospital National Patient Safety Goals reports that the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery applies to all surgical and nonsurgical invasive procedures. Evidence indicates that procedures that place the patient at the most risk include those that involve general anesthesia or deep sedation, although other procedures may also affect patient safety. Hospitals can enhance safety by correctly identifying the patient, the appropriate procedure, and the correct site of the procedure.13
The Universal Protocol is based on the following principles:
- Wrong-person, wrong-site,
and wrong-procedure surgery can and must be prevented.
- A robust approach using
multiple, complementary strategies is necessary to achieve the goal of always
conducting the correct procedure on the correct person, at the correct site.
- Active involvement and use
of effective methods to improve communication among all members of the
procedure team are important for success.
- To the extent possible, the
patient and, as needed, the family, are involved in the process.
The Universal Protocol is
implemented most successfully in hospitals with a culture that promotes
teamwork and where all individuals feel empowered to protect patient safety. A
hospital should consider its culture when designing processes to meet the
Diagnostic errors can include either a total failure to diagnose or a wrong diagnosis. A failure to diagnose is sometimes referred to in the medical community as a "No-Fault Error" where the disease is asymptomatic or presents the symptoms of a much more common condition.
Systemic errors occur when some aspect of the medical system introduces error into the process. Common example of systemic errors include transcription errors on lab results, poor handling techniques, inadequate equipment, and failure of staff to alert physicians to report results in a timely manner.
Finally, and most commonly, are cognitive errors or poor physician decisions. These bad decisions can be based on bad data collection, bad symptom interpretation, flawed reasoning or incomplete knowledge. These can often be traced back to physicians lacking knowledge outside their specialty, failing to follow diagnostic protocols, or failing to consult specialists early in a treatment cycle. Diagnostic errors often fall on a physician's shoulders, although incorrect or incomplete data from nursing and support staff can be a contributing factor.
Catheter-Associated Urinary Track Infections (CAUTI)
A urinary tract infection (UTI) is an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney. The CDC reports that UTIs are the most common type of healthcare-associated infection reported to the National Healthcare Safety Network (NHSN). Among UTIs acquired in the hospital, approximately 75% are associated with a urinary catheter, which is a tube inserted into the bladder through the urethra to drain urine.
Between 15-25% of
hospitalized patients receive urinary catheters during their hospital
stay. The most important risk factor for
developing a catheter-associated UTI (CAUTI) is prolonged use of the urinary
catheter. Therefore, catheters should
only be used for appropriate indications and should be removed as soon as they
are no longer needed.14
Tubing misconnections continue to cause severe patient injury and death, since tubes with different functions can easily be connected using luer connectors, or because connections can be “rigged” (constructed) using adapters, tubing or catheters. This is why new ISO (International Organization for Standardization) tubing connector standards are being developed for manufacturers.15
Close Call/Near Miss
A close call is an event or situation that could have resulted in an adverse event but did not, either by chance or through timely intervention. This is sometimes referred to as near miss incidents.
Some may believe that since there was no patient injury, close calls do not need to be reported or investigated. However, close calls occur 10 to 300 times more frequently than the actual harm events they are the precursors of and provide an organization the opportunity to identify and correct system vulnerabilities before injury or death occurs.
Close calls (also called near misses or good catches) should be prioritized using the Risk Matrix by asking what is a plausible severity or consequence for the event, hazard, or vulnerability, coupled with the likelihood or probability of the event/hazard scenario occurring again. This plausible outcome is then used as the severity or consequence when applying the risk matrix to determine the appropriate response (RCA2 or other actions).16
Reduce the Risk of Healthcare Associated Infections (HAIs)
According to the Centers for Disease Control and Prevention, each year, millions of people acquire an infection while receiving care, treatment, and services in a healthcare organization. Consequently, healthcare–associated infections (HAIs) are a patient safety issue affecting all types of healthcare organizations.
One of the most important ways to address HAIs is by improving the hand hygiene of healthcare staff. Compliance with the World Health Organization (WHO) or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines will reduce the transmission of infectious agents by staff to patients, thereby decreasing the incidence of HAIs.