Question

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What are major sources of preventable medical errors according to the IOM 1999 Report (https://www.ncbi.nlm.nih.gov/books/NBK2673/) and what are its recommendation to prevent these errors?

Answer 1

A medical error is a preventable adverse effect of medical care, whether or not it is evident or harmful to the patient. Among the problems that commonly occur during providing health care are adverse drug events and improper transfusions, misdiagnosis, under and over treatment, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities. High error rates with serious consequences are most likely to occur in intensive care units, operating rooms, and emergency departments. Medical errors are also associated with extremes of age, new procedures, urgency, and the severity of the medical condition being treated.

Medical errors can be defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Among the problems that commonly occur during the course of providing health care are adverse drug events and improper transfusions, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities. High error rates with serious consequences are most likely to occur in intensive care units, operating rooms, and emergency departments.

A variety of factors have contributed to the nation’s epidemic of medi­cal errors. One oft-cited problem arises from the decentralized and frag­mented nature of the health care delivery system--or “nonsystem,” to some observers. When patients see multiple providers in different settings, none of whom has access to complete information, it becomes easier for things to go wrong.

The Institute of Medicine’s (IOM) legendary report in 1999, "To Err is Human," estimated 98,000 iatrogenic deaths making it the sixth leading cause of death in the U.S.

One of the 1999 IOM report’s main conclusions is that the majority of medical errors do not result from individual recklessness or the actions of a particular group. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. For example, stocking patient-care units in hospitals with certain full-strength drugs, even though they are toxic unless diluted, has resulted in deadly mistakes. Thus, mistakes can best be prevented by designing the health system at all levels to make it safer--to make it harder for people to do something wrong and easier for them to do it right. Of course, individuals should be still held accountable when an error can be attributed to them. As an example, anchoring bias (persistence with an initial diagnostic impression despite evidence of another diagnosis) is a major source of diagnostic error. When an error occurs, however, blaming an individual does little to make the system safer and prevent someone else from committing the same error.

The nine most common medical errors in the United States in 2014, by occurrence are: adverse drug events, catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), injury from falls and immobility, obstetrical adverse events, pressure ulcers, surgical site infections (SSI), venous thrombosis (blood clots), and ventilator-associated pneumonia (VAP).

Types of Errors
Diagnostic

•    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

Treatment

•    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

Preventive

•    Failure to provide prophylactic treatment
•    Inadequate monitoring or follow-up of treatment

Other

•    Failure of communication
•     Equipment failure
•    Other system failure

Although the literature pertaining to errors in health care has grown steadily over the last decade and some notable studies are particularly strong methodologically, we do not yet have a complete picture of the epidemiology of errors. Many studies focus on patients experiencing injury and provide valuable insight into the magnitude of harm resulting from errors. Other studies, more limited in number, focus on the occurrence of errors, both those that result in harm and those that do not (sometimes called ''near misses"). More is known about errors that occur in hospitals than in other health care delivery settings.

Synthesizing and interpreting the findings in the literature pertaining to errors in health care is complicated due to the absence of standardized nomenclature. For purposes of this report, the terms error and adverse event are defined as follows:

An error is defined as the failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning).

An adverse event is an injury caused by medical management rather than the underlying condition of the patient. An adverse event attributable to error is a "preventable adverse event." Negligent adverse events represent a subset of preventable adverse events that satisfy legal criteria used in determining negligence (i.e., whether the care provided failed to meet the standard of care reasonably expected of an average physician qualified to take care of the patient in question).

Path to safety

The most important way you can help prevent errors is to be an active member of your health care team. This means taking part in each decision about your health. Research shows that patients who are more involved with their care tend to get better results.

Keep your health care team informed.

• Make sure that all of your doctors know what medicine(s) you take. This includes prescriptions and over-the-counter drugs, as well as supplements, vitamins, and herbs. At least once a year, bring all of your medicines with you to your doctor.
• Make sure your doctor knows about all allergies you have. This includes if you have had adverse reactions to certain medicines. This can help you avoid getting a medicine that can harm you.
• Make sure that all health professionals involved in your care have important health information about you. Do not assume that everyone knows everything they need to.

Ask to get information about your medicines in terms you can understand.

• Ask for this information both when your medicines are prescribed and when you receive them.
• Ask for written information about the side effects your medicine could cause. If you know what might happen, you will be better prepared. This way, you know what problems to look for and can get help, if needed. Make sure you know if you should call the doctor or get emergency care.
• Ask for a list of ingredients in the medicine. You should check this for possible allergies.
• When your doctor writes a prescription, make sure you can read it. This prevents errors in getting the wrong medicine.

Talk to your pharmacist.

• When you pick up medicine from the pharmacy, confirm that your doctor prescribed it.
• Medicine labels can be hard to understand. Ask questions about the directions. For example, ask if “4 doses daily” means taking a dose every 6 hours around the clock or just during regular waking hours.
• Ask your pharmacist for the best device to measure your liquid medicine. Ask questions if you are not sure how to use it. Research shows that many people do not understand the right way to measure liquid medicines. For example, household teaspoons do not hold a true teaspoon of liquid.

Prevent errors in the hospital.

• If you can, choose a hospital at which many patients have the procedure or surgery you need. Research shows that patients tend to have better results when they are treated in hospitals that have a lot of practice with their condition.
• Make sure all health care workers who have direct contact with you wash their hands. Hand washing is an important way to prevent the spread of infections.
• Before surgery, make sure that you, your doctor, and your surgeon all agree and are clear on exactly what will be done. This can prevent errors and confusion during and after surgery. For example, surgery at the wrong site, such as left knee instead of right knee, is rare. But even once is too often. The good news is that wrong-site surgery is 100 percent preventable. The American Academy of Orthopaedic Surgeons urges surgeons to sign their initials directly on the site to operate on before the surgery.
• When you get discharged from the hospital, ask your doctor to explain the treatment plan you will use at home. This includes learning about your medicines and knowing when you can return to normal life. Research shows that at discharge time, doctors think their patients understand more than they really do.

Take charge of your health care.

• Speak up if you have questions or concerns. You have a right to question anyone who is involved with your care.
• Make sure that someone, such as your primary doctor, is in charge of your care. This is especially important if you have several, ongoing health problems.
• Ask a family member or friend to support your health. They can help keep track of things and speak up for you if you can’t. Even if you think you don’t need help now, you might need it later.

Learn more about your conditions, tests, and treatments.

• Gather as much information as you can from your doctor. In some cases, you may want to get a second opinion. You can do research on your own as well to make sure you understand your problems and options.
• Know that “more” is not always better. Find out why you need a test or treatment and how it can help you. You could be better off without it.
• If you have a test, don’t assume that no news is good news. Follow up to get the results.
• Ask your doctor if your treatment is based on the latest evidence. Treatment recommendations are available from the National Guidelines Clearinghouse. You also can ask your doctor about new trials or studie

Questions to ask your doctor

• Do I have a health condition?
• What tests do I need to confirm the condition?
• What are my treatments options? What are the pros and cons of each option?
• Are there new trials or studies that I should consider?
• Do I need to take medicines? If so, what do you recommend?
• What is the medicine for, or what does it treat?
• What are the possible side effects, and what do I do if they occur?
• How do I take the medicine?
• For how long do I need to take the medicine?
• Is this medicine safe to take with other medicines?
• What foods, drinks, or activities should I avoid while taking this medicine?
• If I need surgery, what is the plan before, during, and after the procedure?