Chapter 4: Medical Errors: A Critical Practice Issue 2 Contact Hours Learning objectives Define terms important to the concept of medical error. Identify strategies for reducing nine common medical errors. Describe the various categories of medical errors. Explain the Affordable Care Act’s impact on medical error Identify factors that contribute to medical error occurrence. reduction. Introduction Medical errors are a silent and largely unseen tragedy. Estimates medical error increase personal and institutional financial burdens, suggest that medical errors and other instances of preventable harm adding estimated billions of dollars to health care costs annually. To at hospitals result in the death of 210,000 to 440,000 Americans each learn more about how, when, and why medical errors occur, federal year. A 2013 study by the Inspector General of the Department of regulations established in 2003 required hospitals participating in Health and Human Services (DHHS) identified 180,000 deaths related the Medicare program to, “track medical errors and adverse patient to medical error in 2010, of which 44% were determined clearly or events, analyze their causes, and implement preventive actions and likely preventable [1]. mechanisms that include feedback and learning throughout the Based on these figures, medical errors are the third leading cause hospital.” Hospitals report this information using a federally-approved of death in America, after heart disease and cancer [2,3]. Beyond Quality Assessment and Performance Improvement (QAPI) the obvious emotional toll, unexpected adverse effects related to program [4]. CNA.EliteCME.com Page 27 While reporting has been compulsory since 2003, survey data presented by the DHHS Office of the Inspector General in 2012 found Evidence-based practice (EBP) alert! Research shows that a high that [5]: percentage of medical errors go unreported. This can lead to a ● Only about 14% of “patient harm events” experienced by dangerous environment for patients. Nurses must take the lead in Medicare beneficiaries were captured by hospital incident accurate reporting of medical errors and the promotion of systems reporting systems. and processes that decrease the potential for error. ● An estimated 86% of total incidents were not reported. ● Of the unreported incidents, 62% were not reported because staff Nurses are essential for developing and maintaining a culture of safety members did not perceive them as reportable. within their organizations and are the professionals most likely to ● 25% of the unreported incidents were described as commonly discover and report adverse events [6]. Thus, it is important that nurses reported but not reported in these cases. work to reduce the risk of medical error and respond appropriately and ● Events were most often reported by nurses who identified them as capably to medical error occurrences. part of the regular course of care. Nursing consideration: Nurses are in a position to help educate their colleagues, not only in nursing but in other disciplines, about ways to prevent medical errors and what to do if one is discovered. This will enhance the safety of the patients’ environments. Definition of terms Medical error is defined as harm to a patient that results from ● Sentinel event: An unexpected occurrence involving death or either [7,8]: serious physical or psychological injury, or the risk of death or ● The failure of a planned action to be completed as intended; or such an injury. ● The use of a wrong plan to achieve an objective. ○ Sentinel event: A sentinel event is an unexpected occurrence Medical error can be associated with failures in medical practice, involving death, serious physical or psychological injury, products, procedures, and/or systems. Medical error requires two or the risk thereof. A sentinel event indicates the need for critical parts: harm and whether the harm or error could have been immediate investigation and response. prevented [7]. ○ The terms “sentinel event” and “error” are not synonymous; not all sentinel events occur because of an error, and not all Other terms related to medical error include [7,8,18]: errors result in sentinel events. ● Safety: Freedom from accidental injury. ● Root cause analysis: Root cause analysis is a process for ● Adverse drug event: An adverse drug event is injury resulting identifying the factors that underlie variation in performance, from the use of a drug. An adverse drug event may be caused by including the occurrence or possible occurrence of a sentinel an adverse drug reaction, a medication error, or an overdose. An event. adverse drug event frequently necessitates discontinuation of the ○ A root cause analysis focuses primarily on systems and drug. processes, not on individual performance. ● Adverse drug reaction: An adverse drug reaction is an unavoidable, ○ The analysis progresses from special causes in clinical appreciably noxious, or unpleasant reaction that occurs during the processes to common causes in organizational processes normal, proper use of a medical product. Some drug reactions may and systems and identifies potential improvements in be minor and temporary; others have the potential to be permanent these processes or systems that would tend to decrease the and serious. likelihood of such events in the future or determines, after ● Medication errors: Medication errors are defined as errors that analysis, that no such improvement opportunities exist. occurs due to mistakes made in the processes of the drug’s prescribing, transcribing, dispensing, administering, or monitoring. Nursing consideration: Nurses must be able to recognize and ● Near-miss: An error that is detected and corrected before harm can report important factors related to medical error or potential medical be done. error in order to adequately promote a culture of safety. Categories of medical errors Many preventable adverse events can be associated with more than ● Medication errors: Medication errors are “any preventable event one type of medical error. There are many different ways to categorize that may cause or lead to inappropriate medication use or patient medical error, and categories may overlap, but the following harm while the medication is in the control of the health care classifications are common. professional, patient, or consumer” [11]. ● Diagnostic errors: Diagnosis errors are errors that occur when a diagnosis is missed, wrong, or delayed [9]. Nursing consideration: Adhering to the eight “rights” of ● Systems or process errors: Systems or process errors involve medication administration helps nurses avoid medication errors. predictable human failings in the context of poorly designed These eight rights are [12]: systems [10]. 1. Right patient. ● Active errors: Active errors nearly always involve frontline staff 2. Right medication. members and occur at the point of contact between a human and 3. Right dose. some part of a larger system [10]. 4. Right route. ● Latent errors: Sometimes referred to as “accidents waiting to 5. Right time. happen,” latent errors involve failures of organization or design 6. Right documentation. (e.g., systems and processes) that allow active errors to cause 7. Right reason. harm [10]. 8. Right response. Page 28 CNA.EliteCME.com ● Infection related errors: According to the U.S. Centers for ● Laboratory errors: Errors made in the laboratory can be Disease Control and Prevention (CDC) there are 1.7 million health technical, procedural, or the result of poor communication. The care-associated infections every year. Approximately 22% are ECRI Institute evaluated 2,420 mistakes that occurred between infections of surgical wounds; 32% are urinary tract infections 2011 and mid-2013. Only 4% of reported potentially harmful (UTIs); the remainder is infections of the lungs, blood, and other errors occurred in the laboratory itself. Nearly 75% of mistakes parts of the body [13]. It is impossible to estimate the percentage occurred in the pre-analytic stage, defined as the time frame in of hospital acquired infections that are unavoidable, but evidence which tests are selected and ordered, specimens are identified and shows that many of these infections can and should be prevented. transported, and patients are prepared. Such mistakes were more For example, failure to conform to hand hygiene standards can likely to be linked to labels that had the wrong patient’s name, the lead to preventable infections. wrong specimen ordered, and incomplete or mission information. ● Surgical errors: Wrong-site, wrong-procedure, wrong-patient The other 22% occurred in the post-analytic stage, when results errors (WSPEs) should never occur and indicate serious safety were interpreted, reported, or stored [16]. problems within an organization. Recent studies show that these types of errors occur in about one of 112,000 surgical procedures Nursing consideration: Any discussion of medical errors needs to or that an individual hospital would experience such an error every include clarification of “never ever events.” This term was first used 5 to 10 years. However, these data only include procedures in the in 2001 by Ken Kizer, MD, former CEO of the National Quality operating room. If procedures performed in other settings such as Forum in reference to especially shocking medical errors that should ambulatory surgery centers were to be included, the rate of such never occur. The list of these issues consists of 29 events grouped errors may be significantly higher [14]. into seven categories.