Posts Tagged "medical errors"

Medical Errors: An Update

Medical Errors: An Update

Posted By on Feb 4, 2015

Surgical Errors Based on Wrong Medication Not Uncommon

You may have suffered a surgical error and are dealing with terrible consequences, or have lost a loved one due to a surgical error. Some surgical errors relate to instruments or sponges being left in the body after surgery, but there can be other causes. For example, administering a wrong medication or wrong dosage is also a common type of medical negligence.

How Could This Type of Error Happen?

Surgeons and other medical professionals (as well as people generally) have a tendency to see what they expect to see. This tendency even has a name – “ascertainment bias” – a form of cognitive error. A team of medical providers in a hospital setting who work together often may tend to trust each other based on prior knowledge. So, when a medication is brought to a surgeon to give to a patient, the surgeon may trust all those who handled that medication, beginning with the pharmacist and ending with the person holding the medication who hands it to him.

That expectation held by the surgeon that others can be trusted to provide the correct medication plays a role in this ascertainment bias.

A Quick Check of Medication Can Drastically Change a Patient’s Outcome

Medical malpractice errors related to giving the wrong medicine or an incorrect dosage can sometimes have terrible results. A recent tragic case in Massachusetts exemplifies the problem of a doctor having an ascertainment bias and trusting in all those who handled a medicine before him.

The surgeon looks at a drug handed over by a nurse, and is convinced that it is the right medication because it appears to be the correct medication – yet it is not. He did not read the label. The wrong medication can cause serious medical conditions, some permanent, or in many tragic cases, loss of life.

Although medical professionals must have a high level of trust in each other, every possible point at which an avoidable error is detectable should be part of standard safety protocols for surgery and all treatments involving the administration of medications. Surgeons and nurse practitioners should be required, for example, to submit detailed written prescriptions to pharmacists.

Avoidable Injuries in Hospitals at an All Time High

Medical errors are the third leading cause of death in the nation, following heart disease and cancer. Overdoses due to wrong amount of medication, or the wrong drug being administered are of great concern because these errors add to those unfortunate deaths.

A recent report estimates that 210,000 people die each year due to a preventable medical error, with the actual numbers estimated to be closer to 440,000. Serious harm to a patient is estimated to be 10 to 20 times more common than these lethal mistakes. These numbers are unnerving and are certainly cause for patients to be vigilant and proactively involved in their medical care. Sometimes simply stepping outside the norm of fully accepting all that a doctor says and does at face value and asking questions about treatment can be enough to make a doctor be more attentive. If a doctor knows he or she is being questioned, they may be more concerned about potential medical malpractice suits and therefore do their work more mindfully.

Roughly a sixth of all deaths in the USA could be attributed to a medical error, according to the report. Some disagreement exists about the numbers of deaths due to avoidable mistakes, but no one is disputing the fact that no matter what tracking system is used to measure the numbers, deaths resulting from medical errors is a serious problem.

A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. Journal of Patient Safety
How Many Die from Medical Mistakes in U.S. Hospitals? NPR

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Medical errors continue to be one of our country’s leading causes of injury and death. Fortunately, medical device entrepreneur and Founder/CEO of Masimo Corporation, Joe Kiani, along with his patient safety group, Patient Safety Movement Foundation, is actively pursuing ways to reduce the number of medical errors resulting in injury or death.

According to the Patient Safety Movement, the number of deaths caused by medical errors now exceeds the number of deaths attributed to vehicle-related accidents, breast cancer and heart failure. An estimated 440,000 deaths and millions of injuries each year are caused by medical errors.

What Actions Are Being Taken to Reduce the Number of Medical Errors?

The Patient Safety Movement has as its goal the implementation of actionable patient safety solutions (APSS) that will bring about zero preventable deaths by 2020. Mr. Kiani is determined to take a stand against this type of medical malpractice. He vehemently believes Congress should pass a law prohibiting Medicare from reimbursing doctors and hospitals for procedures that lead to the accidental death of a patient. He also wants hospitals held accountable for their actions and is certain that transparency among medical practitioners could make a significant difference.

To further his cause, his patient safety group has been hosting an annual summit where patients, healthcare providers, medical technology companies and officials responsible for creating public policies can gather for the purpose of coming up with ideas and drafting strategies that will ultimately reduce the number of deaths caused by avoidable medical errors.

California Senator Barbara Boxer is a steadfast advocate as well. She is not only working to draw attention to the cause, but is actively taking steps to hold hospitals more accountable. The OC Register reports that Sen. Boxer has asked 283 California hospitals to provide her office with detailed information on the actions being taken to reduce on-site medical errors. She has also begun touring many hospitals in the state, including Children’s Hospital of Orange County (CHOC), in an effort to make hospital workers and the general public more aware of this widespread problem, and to initiate actions that protect patients. The University of Michigan reports it has been spearheading state efforts to create new statewide standards for children’s medicines, in an effort to dramatically reduce dosage errors.

Is Human Error Largely to Blame?

Close to 80 percent of all negative or injurious events in our healthcare system occur due to human error, the Patient Safety Movement reports. Incorrect diagnoses, improper treatment, failure to provide adequate care and medication errors are largely to blame. There are many instances, however, where it is the system itself causing problems, rather than individual doctor negligence or failures.

One of the factors that has made this growing problem worse is that although hospitals are required to report medical errors as one of the conditions of being paid by Medicare, an investigation conducted by the Department of Health and Human Services in 2012 found the majority of preventable medical errors were not being reported. Those hospitals that do report such errors often do not take the procedural actions necessary after such an incident to prevent them in the future. While some progress is being made in reducing medical errors, there are still many obstacles that must be overcome. And, according to the Patient Safety Movement’s website, “Getting to ZERO will take all of us working together – clinicians, administrators, medical technology companies, payers, government, and patients.”

Patient Safety Movement:
Orange County Register:
University of Michigan:

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