Medical errors in healthcare practices
Modern medicine has come a long way in terms of diagnostic and therapeutic advances. Earlier, patient safety was not one of the primary concerns today, where the thrust is on a patient-centric approach. Medical errors are a serious healthcare challenge and one of the leading causes of death in India and worldwide. Recognizing the causes and finding viable, long-lasting solutions to prevent their recurrence is important for patient safety.
Rather than individual responsibility, it is a collective challenge for the entire hospital-team to implement viable solutions that will help decrease the errors. Thus, the morbidity and the mortality associated with it, along with healthcare workers’ safety.
Medical Errors Types
The classification of medical errors (acts of commissions or omissions) includes:
- Error or delay in diagnosis
- Failure to employ indicated tests
- Use of outmoded tests or therapy
- Failure to act on results of monitoring or testing
- Error in the performance of an operation, procedure, or test
- Error in administering the treatment
- Error in the dose or method of using a drug
- Avoidable delay in treatment or in responding to an abnormal test
- Inappropriate (not indicated) care
- Failure to provide prophylactic treatment
- Inadequate monitoring or follow-up of treatment
- Failure of communication
- Equipment failure
- Other system failures
SOURCE: Leape, Lucian; Lawthers, Ann G.; Brennan, Troyen A., et al. Preventing Medical Injury. Qual Rev Bull. 19(5):144–149, 1993
Medical Errors Definitions
Medical errors are not homogenous. Thus, it has been difficult to define them. They depend upon various factors, the availability of trained personnel in a given geographic time and place, and the standard of care prevalent in similar circumstances. Thus, due to the lack of a clear definition, medical errors do not have a uniform yardstick of measurement.
Thus, the absence of a definition and the lack of measurement have led to inadequate data collection, processing, and analysis of the data.
Medical errors can be real or perceived. It leads to a deep impact on treating physicians and surgeons’ physical, mental, and social well-being. It has been shown to lead to anger, guilt, depression, and suicide as the doctors encounter the triad of worthlessness, hopelessness, and helplessness.
Compounded with the threat of possible legal action, besides the ethical disciplinary action, at times, they may lose confidence and self-esteem. When entering practice, the clinicians abide by the Hippocratic Oath and the principle of primum-non-nocere (Do no harm). However, medical errors can lead to the feeling of inflicting harm, with self-blame.
Code of Ethics
Medicine is governed by dual things: The law of the land and the Code of Ethics. Violation of the latter leads to disciplinary actions by the associated state or regional medical councils with which the doctor is associated. Whereas, violation of the former (In Indian Penal Code section 320 IPC deals with criminal negligence) leads to legal action in a country’s courts.
There is often a dilemma between the fear of punitive action and the concern of patient safety, which holds them back from reporting errors due to self or due to others.
Often at times, due to strict and rigid workplace-errors policy, medical staff do not report or document an error while hushing it up under the carpet. However, a failure to report leaves the problem unaddressed and further compromises patient safety. Thus, the cycle of errors, non-structured attempts to minimize them, and recurrence keep going unless the root causes are identified and corrective steps are taken.
However, when such errors come to the fore (as they inevitably do), the doctors and the hospital’s reputation is at stake. The emergent negative public opinion can have a devastating effect on healthcare workers’ reputation and health.
Medical Errors: Perspective
Medicine is not a perfect science, and hence, some errors are inevitable due to inherent variations in the biology of individuals and the limits of medical technology. Thus, the term ‘error’ may, at times, refer to a negative connotation that pins the blame on the medical professional when the cause might not even be attributable to the healthcare worker. Consequently, he may be less efficient at work, which will inevitably affect patient outcomes.
However, the term ‘medical error’ has become an integral part of medical jurisprudence, and over time, its definitions and scope have evolved. As with modern afflictions, medical errors are multifactorial in origin. According to the WHO, the most common cause of medical errors is miscommunication. Thus, an ineffective or lack of communication is the starting event in a chain of events that may result in an adverse patient outcome—for example, a wrong-side limb surgery or exchange of patient identity.
The margin of acceptability for medical errors is almost nil, as it deals with human beings’ lives and warrants the highest degree of caution and standard care.
Identifying and acknowledging errors is the first step in the list of improvement strategies.
Fixing an Accountability
The blame for systemic inefficiencies should not be pinned on individuals as soft targets. Thus, punitive actions are considered counter-productive, which does not lead to better future outcomes. Contrarily, it promotes a culture that would be hesitant to admit mistakes and genuine errors.
Multifactorial problems require multimodal involvement and integration across various administration lines: Legal, Medical, and Governmental. Besides being viewed as a defect in the medical services provision, errors should be seen as an opportunity to reform the education and delivery concerning healthcare services.
While accountability must be assigned, and periodic audits must be carried out by an independent third-party, it is equally important to set targets for improvements.
A common goal of hospitals the world over is to offer maximal care with minimal adverse events. A collective effort at streamlining the services with appropriate context-specific protocols will lead to decreased morbidity, mortality, and decreased healthcare costs (including insurance premiums and out-of-pocket expenditures).
Medical Errors Prevention
To check the medical errors, a Joint Commission on Patient Safety Goals was established. It has set various protocols, standards, and goals to have a safe working environment for the healthcare professionals and a positive hospital-visit for the patient.
These measures include:
The doctor is responsible for the safety and well-being of the patients under his care. In a medical team, the treating physician is compared to the Captain of the Ship. Thus, the liability of the deeds of the entire team rests on the doctor.
However, many errors are not directly attributable to the doctor, and thus, it becomes difficult to fix accountability. Thus, to prevent adverse events, there is a WHO Surgical Safety Checklist, for example, in surgery. It encompasses all the factors from patient identification, consent, and site marking for the surgery to procedural steps and the reporting of surgery and equipment malfunctioning steps.
As described earlier, punitive action discourages reporting and leads to humiliation and a negative vicious downward spiral. The administrators and the hospital’s review boards must not humiliate the physician and rather focus on preventing future incidents. This serves dual purposes: Acknowledging deficiencies and new learnings and improvement efforts that are free from the fear of retribution. This will lead to constant improvement towards an ideal administration.
The healthcare provider must be aware of the patients’ rights and duties and the physician’s rights and duties. It is all the more important in today’s era as a stress-free post-operative period, and outcome dependent treatment with a patient-centric approach takes the front seat.
Rather than justifying certain preventable errors as inevitable in a hospital setting, it is important to reduce the infections resulting from, for example, instrumentation and catheterization: Surgical site infections, adverse drug reactions, central-line associated bloodstream infections, and hospital-acquired infections (urinary tract infection and ventilator-associated pneumonia). A commitment to achieving the set targets for decreasing the above-mentioned infection rates goes a long way.
These result from the first line contact between the patient and the members of the treating team, such as doctors or nurses. Development of bedsores or thrombophlebitis of the vein secondary to an IV injection are examples of active errors.
An adverse event refers to an unanticipated surgical or medical complication in the course of treatment. It occurs when the set standards by professional bodies are not followed through. However, some adverse events may be non-preventable. For example, if a ceiling falls on a patient who is admitted to a post-operative ward. Never events are a special subset, which, as the name suggests, should have never happened at all—for example, a wrong-side surgery.
Latent Errors Avoidance
These refer to those errors which are waiting to happen in the absence of due care and precaution. For example, malfunctioning equipment and poor maintenance can result in an adverse event coupled with active human errors.
Root Cause Correction
It refers to a deficiency or decision that, if corrected or avoided, will eliminate the undesirable consequence. They include Poor hierarchical communication, inadequate knowledge or training, blame game, etc.