Patient Safety: Types of Medical Errors

Introduction

Definitions

By definition, errors are unintentional and involve either poor planning or poor execution of a process involved in the medical care Medical care Conflict of Interest of individuals.

The WHO defines patient safety as “a framework of organized activities that creates cultures, processes, procedures, behaviors, technologies, and environments in health care that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make error Error Refers to any act of commission (doing something wrong) or omission (failing to do something right) that exposes patients to potentially hazardous situations. Disclosure of Information less likely and reduce its impact when it does occur.”

Impact

• Worldwide, particularly in low- and middle-income countries, the rising number of adverse events occurring while individuals receive care has led to patient safety initiatives.  
• With their growing complexity, health care systems have been linked to an increase in health care–related adverse events.
• 1 in 10 patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship in high-income countries receiving hospital care experience adverse events, and about half of these are preventable.  
• Globally, 4 in 10 patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship receiving care in the outpatient setting experience an adverse event, of which an estimated almost 80% are considered to be preventable. 
• Most detrimental errors involve:
  • Diagnosis
  • Prescribing/medication use
  • Procedures/surgeries

WHO response

• Recognized the considerable burden of patient harm in health care
• Adopted a resolution to identify patient safety as a global health priority
• Proposed formulating a global patient safety action plan in conjunction with members
• Launched the WHO Flagship Initiative, “A Decade of Patient Safety 2020–2030”

Types and Causes of Medical Errors

Medical errors with serious consequences are most likely to occur when there is increased urgency and severity of the medical condition being treated, as in the ED or ICU ICU Hospital units providing continuous surveillance and care to acutely ill patients. West Nile Virus. Medical errors are also associated with extremes of age and new procedures.

Types of medical errors

• Error Error Refers to any act of commission (doing something wrong) or omission (failing to do something right) that exposes patients to potentially hazardous situations. Disclosure of Information of omission: a result of an action not taken
• Error Error Refers to any act of commission (doing something wrong) or omission (failing to do something right) that exposes patients to potentially hazardous situations. Disclosure of Information of commission: a consequence of taking the wrong action

Categories of medical errors

By severity:

• A: No error Error Refers to any act of commission (doing something wrong) or omission (failing to do something right) that exposes patients to potentially hazardous situations. Disclosure of Information (potential for error Error Refers to any act of commission (doing something wrong) or omission (failing to do something right) that exposes patients to potentially hazardous situations. Disclosure of Information only)
• B: Error Error Refers to any act of commission (doing something wrong) or omission (failing to do something right) that exposes patients to potentially hazardous situations. Disclosure of Information prevented before affecting the individual
• C: Error Error Refers to any act of commission (doing something wrong) or omission (failing to do something right) that exposes patients to potentially hazardous situations. Disclosure of Information that affected the individual, but will not likely be a source of harm to the individual
• D: Error Error Refers to any act of commission (doing something wrong) or omission (failing to do something right) that exposes patients to potentially hazardous situations. Disclosure of Information that affected the individual and required monitoring and/or an action by the provider to prevent harm
• E: Error Error Refers to any act of commission (doing something wrong) or omission (failing to do something right) that exposes patients to potentially hazardous situations. Disclosure of Information that could have caused temporary harm
• F: Error Error Refers to any act of commission (doing something wrong) or omission (failing to do something right) that exposes patients to potentially hazardous situations. Disclosure of Information that could have caused temporary harm and required initial or prolonged hospitalization Prolonged Hospitalization Surgical Infections
• G: Error Error Refers to any act of commission (doing something wrong) or omission (failing to do something right) that exposes patients to potentially hazardous situations. Disclosure of Information that could have negatively affected the individual permanently or long term
• H: Error Error Refers to any act of commission (doing something wrong) or omission (failing to do something right) that exposes patients to potentially hazardous situations. Disclosure of Information that might end an individual’s life without medical intervention
• I: Error Error Refers to any act of commission (doing something wrong) or omission (failing to do something right) that exposes patients to potentially hazardous situations. Disclosure of Information that could have resulted in death

By conceptual grouping:

• Diagnostic:
  • Error Error Refers to any act of commission (doing something wrong) or omission (failing to do something right) that exposes patients to potentially hazardous situations. Disclosure of Information or delay in diagnosis
  • Failure to order indicated tests
  • Not using current evidence for tests or therapy
  • Failure to act on results of monitoring or tests
• Treatment:
  • Error Error Refers to any act of commission (doing something wrong) or omission (failing to do something right) that exposes patients to potentially hazardous situations. Disclosure of Information in the performance of an operation, procedure, or test
  • Error Error Refers to any act of commission (doing something wrong) or omission (failing to do something right) that exposes patients to potentially hazardous situations. Disclosure of Information in treatment administration
  • Error Error Refers to any act of commission (doing something wrong) or omission (failing to do something right) that exposes patients to potentially hazardous situations. Disclosure of Information in the dose or method of using a drug
  • Avoidable delay in treatment or responding to an abnormal test
  • Inappropriate care (not indicated)
• Preventive:
  • Failure to provide prophylactic treatment
  • Failure to prevent infection by accepted measures
  • Inadequate monitoring or follow-up of treatment
• Other:
  • Failure of communication Communication The exchange or transmission of ideas, attitudes, or beliefs between individuals or groups. Decision-making Capacity and Legal Competence
  • Equipment failure
  • Other system failures

Contributing factors

• Communication Communication The exchange or transmission of ideas, attitudes, or beliefs between individuals or groups. Decision-making Capacity and Legal Competence problems:
  • Written or verbal
  • Between members of the team or with patient
  • Not using qualified interpreters when needed
  • Increasing fragmentation Fragmentation Chronic Apophyseal Injury of health care → more care transitions → more opportunity for error Error Refers to any act of commission (doing something wrong) or omission (failing to do something right) that exposes patients to potentially hazardous situations. Disclosure of Information
• Inadequate information flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure:
  • Lack of essential information for prescribing
  • Lack of appropriate communication Communication The exchange or transmission of ideas, attitudes, or beliefs between individuals or groups. Decision-making Capacity and Legal Competence about test results
  • Poor coordination Coordination Cerebellar Disorders of medication orders for transfer of care
• Human problems:
  • Not following standards of care, policies, or procedures
  • Inadequate or incorrect knowledge to provide the care needed
• Patient-related issues:
  • Inadequate patient identification Identification Defense Mechanisms, assessment, or education
  • Failure to obtain consent
• Organizational transfer of knowledge: insufficient training
• Inadequate staffing
• Technical failures: medical device or equipment failure
• Inadequate or lack of policies and procedures

Most common patient safety issues (included in medical “errors”) in the United States

• Adverse drug events
• Catheter-associated urinary tract infection Catheter-Associated Urinary Tract Infection Multidrug-resistant Organisms and Nosocomial Infections
• Central line–associated bloodstream infection
• Injury from falls and immobility
• Obstetrical adverse events
• Pressure ulcers
• Surgical site infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease
• Venous thrombosis Venous thrombosis The formation or presence of a blood clot (thrombus) within a vein. Budd-Chiari Syndrome
• Ventilator-associated pneumonia Ventilator-Associated Pneumonia Multidrug-resistant Organisms and Nosocomial Infections
• Wrong site/wrong procedure surgery

Most common misdiagnosed conditions

• In the ED:
  • Acute stroke ( cerebrovascular accident Cerebrovascular accident An ischemic stroke (also known as cerebrovascular accident) is an acute neurologic injury that occurs as a result of brain ischemia; this condition may be due to cerebral blood vessel occlusion by thrombosis or embolism, or rarely due to systemic hypoperfusion. Ischemic Stroke)
  • MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction
  • Spinal epidural abscess Epidural abscess Circumscribed collections of suppurative material occurring in the spinal or intracranial epidural space. The majority of epidural abscesses occur in the spinal canal and are associated with osteomyelitis of a vertebral body; analgesia, epidural; and other conditions. Clinical manifestations include local and radicular pain, weakness, sensory loss, urinary incontinence, and fecal incontinence. Cranial epidural abscesses are usually associated with osteomyelitis of a cranial bone, sinusitis, or otitis media. Retropharyngeal Abscess
  • Pulmonary embolism Pulmonary Embolism Pulmonary embolism (PE) is a potentially fatal condition that occurs as a result of intraluminal obstruction of the main pulmonary artery or its branches. The causative factors include thrombi, air, amniotic fluid, and fat. In PE, gas exchange is impaired due to the decreased return of deoxygenated blood to the lungs. Pulmonary Embolism
  • Necrotizing fasciitis Necrotizing fasciitis Necrotizing fasciitis is a life-threatening infection that causes rapid destruction and necrosis of the fascia and subcutaneous tissues. Patients may present with significant pain out of proportion to the presenting symptoms and rapidly progressive erythema of the affected area. Necrotizing Fasciitis
  • Meningitis Meningitis Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Meningitis
  • Testicular torsion Testicular torsion Testicular torsion is the sudden rotation of the testicle, specifically the spermatic cord, around its axis in the inguinal canal or below. The acute rotation results in compromised blood flow to and from the testicle, which puts the testicle at risk for necrosis. Testicular Torsion
  • Subarachnoid hemorrhage Subarachnoid Hemorrhage Subarachnoid hemorrhage (SAH) is a type of cerebrovascular accident (stroke) resulting from intracranial hemorrhage into the subarachnoid space between the arachnoid and the pia mater layers of the meninges surrounding the brain. Most SAHs originate from a saccular aneurysm in the circle of Willis but may also occur as a result of trauma, uncontrolled hypertension, vasculitis, anticoagulant use, or stimulant use. Subarachnoid Hemorrhage
  • Sepsis Sepsis Systemic inflammatory response syndrome with a proven or suspected infectious etiology. When sepsis is associated with organ dysfunction distant from the site of infection, it is called severe sepsis. When sepsis is accompanied by hypotension despite adequate fluid infusion, it is called septic shock. Sepsis and Septic Shock
  • Fractures
  • Appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis
• Recurring themes in unexpected deaths:
  • Atypical presentations of unusual problems
  • Chronic diseases with decompensation
  • Abnormal vital signs (most often tachycardia Tachycardia Abnormally rapid heartbeat, usually with a heart rate above 100 beats per minute for adults. Tachycardia accompanied by disturbance in the cardiac depolarization (cardiac arrhythmia) is called tachyarrhythmia. Sepsis in Children) at discharge
  • New medical conditions in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with a mental disability Disability Determination of the degree of a physical, mental, or emotional handicap. The diagnosis is applied to legal qualification for benefits and income under disability insurance and to eligibility for social security and workman’s compensation benefits. ABCDE Assessment or psychiatric problems

Medical Error Prevention

Strategies for improving the prevention of errors that affect patient safety have been implemented in a wide variety of patient care areas. Many of these involve reducing health care–associated infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease or complications, which are not by definition “errors” but are included as such in the patient safety literature when they are thought to be preventable.

Patient safety tips for hospitals

The Agency for Healthcare Research Research Critical and exhaustive investigation or experimentation, having for its aim the discovery of new facts and their correct interpretation, the revision of accepted conclusions, theories, or laws in the light of newly discovered facts, or the practical application of such new or revised conclusions, theories, or laws. Conflict of Interest and Quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement (AHRQ) has published 10 evidence-based patient safety tips to prevent adverse events in hospitals:

• Prevent central line–associated bloodstream infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease by:
  • Handwashing
  • Using full-barrier precautions
  • Cleaning the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions with chlorhexidine
  • Avoiding femoral lines
  • Removing unnecessary lines
• Redesign hospital discharge:
  • Assign a dedicated staff member to work closely with patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship and with other staff for medication reconciliation and scheduling follow-up appointments.
  • Create an easy-to-understand discharge plan with a medication schedule, follow-up appointments, and phone numbers to call if problems should arise.
• Prevent hospital-acquired venous thromboembolism Thromboembolism Obstruction of a blood vessel (embolism) by a blood clot (thrombus) in the blood stream. Systemic Lupus Erythematosus ( VTE VTE Obstruction of a vein or veins (embolism) by a blood clot (thrombus) in the bloodstream. Hypercoagulable States):
  • Considered a preventable cause of hospital deaths
  • Create a VTE VTE Obstruction of a vein or veins (embolism) by a blood clot (thrombus) in the bloodstream. Hypercoagulable States protocol using an evidence-based guide to identify best practices.
• Educate patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship on safe anticoagulant use:
  • Anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants are among the top causes of adverse drug events.
  • If used incorrectly, they can cause uncontrollable bleeding.
• Limit Limit A value (e.g., pressure or time) that should not be exceeded and which is specified by the operator to protect the lung Invasive Mechanical Ventilation shift durations for medical residents and other hospital staff, if possible:
  • Adhere to a maximum 80-hour workweek.
  • Limit Limit A value (e.g., pressure or time) that should not be exceeded and which is specified by the operator to protect the lung Invasive Mechanical Ventilation residents who work 30-hour shifts to a maximum of 16 consecutive hours of patient care plus a 5-hour protected sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep period during the night hours.
• Collaborate with a patient safety organization (PSO), which:
  • Helps others avoid preventable errors
  • Creates a secure and confidential environment where data can be collected, aggregated, and analyzed to improve quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement and reduce risks
• Use sound hospital design principles:
  • To prevent falls: well-designed patient rooms and bathrooms 
  • To allow easy access to patient rooms: decentralized nursing stations
  • To reduce medication errors: well-lit, quiet, private space for pharmacists to fill prescriptions without distractions 
  • To reduce infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease: single-bed rooms, multiple convenient locations for handwashing, and improved air filtration systems
• Measure the hospital’s patient safety culture:
  • Survey hospital staff to assess patient safety culture.
  • Evaluate the impact of interventions and track changes over time.
• Build teams and rapid response systems:
  • Train hospital staff in effective team communication Communication The exchange or transmission of ideas, attitudes, or beliefs between individuals or groups. Decision-making Capacity and Legal Competence.
  • Use tools that provide evidence-based techniques for improving team communication Communication The exchange or transmission of ideas, attitudes, or beliefs between individuals or groups. Decision-making Capacity and Legal Competence for rapid response teams.
• Provide safe chest tube insertion based on the mnemonic UWET:
  • Universal precautions ( sterile Sterile Basic Procedures cap, mask, gown, gloves)
  • Wider skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions prep
  • Extensive draping Draping Examination of the Breast
  • Tray positioning

Specific types of errors and strategies for prevention

• Action or skill-based errors:
  • Require immediate and associative thinking
  • Examples:
    • Skipping a step in medication dilution
    • “Pattern matching,” such as assuming chest pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways is due to an MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction instead of considering a comprehensive differential diagnosis
  • Prevention of fast-thinking errors:
    • Use checklists for steps of a procedure.
    • Avoid distractions during critical tasks.
    • Implement evidence-based clinical practice guidelines.
    • Build checks into systems, such as 2-person verification.
• Decision-based errors:
  • Involve logical thinking that requires a conscious effort
  • Often occur during a crisis 
  • May be compounded by persisting in following an incorrect path
  • Examples:
    • Faulty knowledge or judgment Judgment The process of discovering or asserting an objective or intrinsic relation between two objects or concepts; a faculty or power that enables a person to make judgments; the process of bringing to light and asserting the implicit meaning of a concept; a critical evaluation of a person or situation. Psychiatric Assessment, such as incorrect treatment choice
    • Critical thinking failure, such as incorrect diagnosis
  • Prevention of decision-based errors:
    • Simulation training for specific clinical scenarios
    • Cognitive aids AIDS Chronic HIV infection and depletion of CD4 cells eventually results in acquired immunodeficiency syndrome (AIDS), which can be diagnosed by the presence of certain opportunistic diseases called AIDS-defining conditions. These conditions include a wide spectrum of bacterial, viral, fungal, and parasitic infections as well as several malignancies and generalized conditions. HIV Infection and AIDS such as algorithms and computerized decision support
• Technical errors:
  • Occur when the task exceeds the clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship’s proficiency or when the patient’s anatomy is abnormal and complex
  • Example: intubating the esophagus Esophagus The esophagus is a muscular tube-shaped organ of around 25 centimeters in length that connects the pharynx to the stomach. The organ extends from approximately the 6th cervical vertebra to the 11th thoracic vertebra and can be divided grossly into 3 parts: the cervical part, the thoracic part, and the abdominal part. Esophagus: Anatomy instead of the trachea Trachea The trachea is a tubular structure that forms part of the lower respiratory tract. The trachea is continuous superiorly with the larynx and inferiorly becomes the bronchial tree within the lungs. The trachea consists of a support frame of semicircular, or C-shaped, rings made out of hyaline cartilage and reinforced by collagenous connective tissue. Trachea: Anatomy
  • Prevention of technical errors:
    • Implement known safety precautions for skill-based tasks (e.g., ultrasound guidance for central line placement)
    • Conscious evaluation of the task and one’s proficiency; having backup expertise available
• Communication-based errors:
  • Result in an unintended act that leads to adverse events that cause patient harm
  • Examples:
    • Surgeon’s communication Communication The exchange or transmission of ideas, attitudes, or beliefs between individuals or groups. Decision-making Capacity and Legal Competence misheard by the anesthesiologist
    • Hospitalist communication Communication The exchange or transmission of ideas, attitudes, or beliefs between individuals or groups. Decision-making Capacity and Legal Competence regarding acting on a critical pending test result missed by the physician who is assuming responsibility for patient care on the next shift
  • Prevention of errors based on poor communication Communication The exchange or transmission of ideas, attitudes, or beliefs between individuals or groups. Decision-making Capacity and Legal Competence:
    • Use structured communication Communication The exchange or transmission of ideas, attitudes, or beliefs between individuals or groups. Decision-making Capacity and Legal Competence, such as requiring the receiver to repeat the message as heard and having the sender verify accuracy.
    • Numerous accrediting agencies for hospitals in the United States now require education regarding handoffs of patient care between providers.

A Culture of Safety in Health Care

It is essential that healthcare organizations establish a culture of safety that focuses on system improvement and views preventable medical errors as opportunities to improve patient care processes.

• Establish a culture of safety:
  • Every individual must assume responsibility to monitor and report medical errors or near misses.
  • Organizations must collect, analyze, and learn from the data collected.
• Human errors will occur:
  • Avoid blame, shame, or punitive Punitive Punishment to the doctor for gross negligence or carelessness (e.g., prison time, suspension of medical license). Malpractice approach toward the individual.
  • Provide confidential support for clinicians to work through feelings of anger, guilt, inadequacy, depression, and potential suicidal thoughts after a serious medical error Error Refers to any act of commission (doing something wrong) or omission (failing to do something right) that exposes patients to potentially hazardous situations. Disclosure of Information.
  • Identify ways to mitigate preventable errors and improve patient safety.
• Develop a learning culture oriented toward patient safety and continual improvement.
• Provide a framework for balanced accountability of the individual and the organization in designing workplace systems that are safe and reliable.
• When medical errors occur:
  • Provide full disclosure and an apology to the patient to decrease anger and blame, increase trust Trust Confidence in or reliance on a person or thing. Conflict of Interest, and improve relationships.
  • An apology includes acknowledging the error Error Refers to any act of commission (doing something wrong) or omission (failing to do something right) that exposes patients to potentially hazardous situations. Disclosure of Information and its consequences and communicating regret.