journal of patient safety report 2013 preventable medical errors

Abstract

The authors present a viewpoint regarding the quality of data used in estimating the number of preventable hospital deaths in the United States.

NATIONAL TRANSPORTATION SAFETY BOARD

We have used the NTSB to illustrate shortcomings in the United States' patient safety initiatives. Many healthcare advocates are calling for the formation of a body similar to the NTSB to at least investigate clusters of adverse events.

WHY ARE THESE NUMBERS AND MEASURING MORTALITY IMPORTANT?

Some have asserted that the “problem in patient safety has been unrealistic expectations that hospitals can tackle problems, which we do not yet have a solution,” 2 is contradicted by decades of established research. Advocates are not calling for the prevention of problems for which solutions are not known, but calling to implement known solutions.

WE CAN DO BETTER

The United States healthcare system as a whole can substantially decrease the incidence of adverse events and associated deaths. The AHRQ has estimated using a 2010/2011 baseline that 44% of HACs are preventable.

CONCLUSIONS

Advocates are not calling to prevent problems for which solutions are not known but calling to implement known solutions to prevent all too common problems. What ties the occurrence of preventable adverse events and mortality together is the willingness and determination of facilities to adopt a culture of safety and invest in patient safety.

What is preventability in a case?

The prevailing view is that “preventability” of an adverse event links to the commission of an identifiable error that caused an adverse event. Adverse events that cannot be traced to a likely error should not be called “preventable.”.

What is a lethal error of communication?

Errors of communication can occur between 2 or more providers or between providers and patient. One example of a lethal error of communication between provider and patient occurred when cardiologists failed to warn their 19-year-old patient not to run.

How many patients were treated in tertiary hospitals in 2004?

In a somewhat similar study published in March 2011 in the journal Health Affairs, investigators examined the medical records of 795 patients treated in 1 of 3 tertiary hospitals in the month of October 2004. 18 These hospitals had been recognized for their efforts to improve patient safety. The investigators also used the GTT to discover adverse ...

What is the 2 tier approach to medical records?

All studies used a 2-tier approach that consisted of screening of medical records by nonphysicians, usually nurses or pharmacists, to flag suspect events. In the second tier, physicians examined the suspect events to determine if a genuine adverse event had occurred and, if so, the level of seriousness of the event.

When was the OIG pilot study published?

A pilot study by the OIG was published in 2008 in an effort to explore the effectiveness of search methods for adverse events. 21 As noted in the methods section, this study relied on 5 search methods for flagging potential adverse events in medical records but did not specify whether such events were preventable.

Who wrote the 1999 report "To Err Is Human"?

Harvard 's Lucian Leape —one of the authors of the 1999 "To Err Is Human" report—told ProPublica that he has confidence in James's estimate, adding that the 98,000 IOM estimate was based on "crude" methods.

How many deaths are caused by preventable adverse events?

A new study in the Journal of Patient Safety estimates that preventable adverse events (PAEs) at U.S. hospitals cause as many as 440,000 patient deaths a year—a statistic that would make medical errors the third-leading cause of death in the United States.

How many people were hospitalized between 2002 and 2008?

For the new estimate, James examined four studies on more than 4,200 patients who were hospitalized between 2002 and 2008 using the "Global Trigger Tool," which guides the search for signs of infection, injury, or medical mistakes.

Why are medical errors important?

It is challenging to uncover a consistent cause of errors and, even if found, to provide a consistent viable solution that minimizes the chances of a recurrent event. By recognizing untoward events occur , learning from them, and working toward preventing them, patient safety can be improved. [1]

What are the two types of errors in medical terminology?

A lack of standardized nomenclature and overlapping definitions of medical errors has hindered data analysis, synthesis, and evaluation. There are two major types of errors: Errors of omission occur as a result of actions not taken.

How much do medical errors cost?

Depending on the study, medical errors account for over $4 billion per year. Medical errors cost approximately $20 billion a year. Medical errors in hospitals and clinics result in approximately 100,000 people dying each year.

What is a never event?

Never events are errors that should not ever have happened. A classic example of a never event is the development of pressure ulcers or wrong-site surgery. The National Quality Forum has identified the following as Serious Reportable Events:

What is an active error?

Active errors are those taking place between a person and an aspect of a larger system at the point of contact. Active errors are made by people on the front line such as clinicians and nurses. For example, operating on the wrong eye or amputating the wrong leg are classic examples of an active error.

How does failure mode effect analysis work?

Failure mode effect analysis fosters safety and the prevention of accidents through a proactive process of identifying potential or real failures, causes, and effects. Failure mode effect analysis concludes errors will occur even if healthcare professionals are careful. Failure mode effect analysis engages in a continual process of quality improvement to assess and correct areas where an error has occurred or is likely to occur. The strategy with failure mode effect analysis is to build redundancies to serve as safety nets that trap errors. [11]

Why is it prudent to delete the term "error"?

Due to the negative connotation, it is prudent to limit the use of the term “error” when documenting in the public medical record. However, adverse patient outcomes may occur because of errors; to delete the term obscures the goal of preventing and managing its causes and effects. [4]

What percentage of physicians reported that counting surgical items during an invasive surgical procedure represented a patient safety practice?

Physicians' knowledge of evidence-based safety practices was inconsistent. More than 90% of physicians reported that counting surgical items during an invasive surgical procedure represented a patient safety practice. Positive attitudes about patient safety were revealed by responses, but 44.5 and 44.1%, respectively, agreed or were uncertain about the disclosure of errors to the patients. The pattern of behavior showed that 7.6% of physicians reported to have never been involved in medical errors, and among system failures, ‘overwork, stress or fatigue of health professionals’ was the most highly rated item.

What is patient safety culture in Italy?

In Italy, patient safety culture among hospital physicians has not been extensively studied and our results add information about physicians' knowledge, attitudes and behavior that represent one important step to understand the perceived patient safety climate before implementing initiatives in healthcare organizations. In particular, it is really impressive that so many of the surveyed physicians believe that reporting is an effective measure, and since this is strongly recommended by the Ministry of Health, it may be the consequence of the appeal government institutions or local quality experts providing continuing education courses have on physicians. The results from our study highlight that greater efforts are needed to facilitate the translation of particularly positive attitudes into appropriate practices that have proved to be effective in reducing medical errors.

Why is safety culture important?

Safety culture has become a significant issue for healthcare organizations striving to improve patient safety, and some safety investigations have indicated that organizations need to change their culture to make it ‘easy to do the right thing, and hard to do the wrong thing’ for patient care [ 4 ].

Why are medical errors important?

To conclude, medical errors are an important public health global problem and pose a serious threat to patient safety and quality of care. Although medical errors are inevitable, decisive actions can be taken to noticeably lessen them and enhance patient safety.

Is death associated with ICD code?

As a result, causes of death not associated with an ICD code, which includes human and system factors, are not documented.[26] . According to the WHO, 117 countries, including India, code their mortality data using the ICD system as the primary indicator of health status.[28] .

What percentage of deaths are due to medical errors?

10 percent of all U.S. deaths are now due to medical error. - Click to Tweet. Third highest cause of death in the U.S. is medical error. - Click to Tweet. Medical errors are an under-recognized cause of death. - Click to Tweet. Analyzing medical death rate data over an eight-year period, Johns Hopkins patient safety experts have calculated ...

Does the CDC classify medical errors separately?

The Johns Hopkins team says the CDC’s way of collect ing national health statistics fails to classify medical errors separately on the death certificate. The researchers are advocating for updated criteria for classifying deaths on death certificates.