Reducing medical errors
Will you die from medical error?
The anatomy of medical error
More on medical mistakes
Reducing preventable medical errors
Preventing 'forgotten surgical items'
Rethinking medical education and training
Improving patient safety and preventing falls
Organizations supporting patient safety and prevention of medical mistakes
"We had a saying in Brooklyn: 'Don't trust anybody.Not even your own fadder.' "
~ Norman Bauman
Medical mistakes are said by some to be the third leading cause of death in the United States, after heart disease and cancer. Will they know that's why you died?
• Malpractice: A Neurosurgeon Reveals How Our Health-Care System Puts Patients at Risk by Lawrence Schlachter MD. "“A surgeon-turned-lawyer’s thoughtful and passionate plea for a more transparent and accountable medical profession."
• Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare by Niran Al-Agba, MD, and Rebekah Bernard, MD. "As mega corporations push for efficiency and tout consumer focused retail services, American healthcare is being dumbed down to the point of no return. It's a story that many media outlets are missing and one that puts you and your family's health at real risk.~John Irvine, Deductible Media..."As corporations seek to save money and government agencies aim to increase constituent access, minimum qualifications for the guardians of our nation’s healthcare continue to decline—with deadly consequences."
• Medical Errors Are Killing Us (Video, Theresa Sabo's talk at TEDxStanleyPark, 4-10-18) If all medical errors were reported, which they aren't, the system would figure out where things are going wrong. If you experience such errors, report them. Change the game.
• Medical Errors: The Silent Killer in Medicine (video, Carol Gunn, TEDxFargo, 9-28-15, 12 minutes) Dr. Gunn shares a powerful story about her sister and the obstacles they faced due to errors in healthcare. She openly wonders why, when medical errors are the third leading cause of death, there is little outage, transparency or accountability.
• Medical Errors Are No. 3 Cause Of U.S Deaths, Researchers Say (Marshall Allen, Olga Pierce, Shots, Health News from NPR, with Pro Publica, 5-3-16). Medical errors rank behind heart disease and cancer as the third leading cause of death in the U.S., Johns Hopkins researchers say. Their study "highlights how shortcomings in tracking vital statistics may hinder research and keep the problem out of the public eye....Medical mistakes that can lead to death range from surgical complications that go unrecognized to mix-ups with the doses or types of medications patients receive....no one knows the exact toll taken by medical errors. [partly] because the coding system used by CDC to record death certificate data doesn't capture things like communication breakdowns, diagnostic errors and poor judgment that cost lives, the study says."
• Will Prosecuting Medical Errors Lead to a Culture of Silence? ( Kristina Fiore, MedPage Today, 3-30-22) Healthcare workers fearful of repercussions from former nurse RaDonda Vaught's conviction. See Nurse Convicted of Neglect and Negligent Homicide for Fatal Drug Error (Brett Kelman,KHN, 3-25-22) RaDonda Vaught, a former nurse criminally prosecuted for a fatal drug error in 2017, was convicted of gross neglect of an impaired adult and negligent homicide Friday after a three-day trial that gripped nurses across the country. Vaught’s trial has been closely watched by nurses and medical professionals across the country, many of whom worry it could set a precedent of criminalizing medical mistakes. Medical errors are generally handled by professional licensing boards or civil courts, and criminal prosecutions like Vaught’s case are exceedingly rare.
• A physician experiences a medical error. Here’s her story. (Maja Castillo, Kevin MD, 10-4-16) "The nurse had erroneously injected epinephrine directly into my bloodstream. For allergic reactions, epinephrine is given into the thigh muscle in a concentration that is ten times stronger than can be injected into the blood....This mistake has been fatal on multiple occasions....Unfortunately, until we can restructure our health care system to prioritize acceptance and openness around medical errors, patients and health care providers alike will continue to suffer."
• Are medical errors really the third most common cause of death in the U.S.? (David Gorski, Science-Based Medicine, 5-9-16) "Estimates of medical errors depend very much on how medical errors are defined, and whether a given death can be attributed to a medical error depends very much on how it is determined whether a death was preventable and whether a given medical error led to that death... These stories all refer to an article last week in BMJ by Martin A Makary and Michael Daniel entitled "Medical error—the third leading cause of death in the US,” which claims that over 251,000 people die in hospitals as a result of medical errors. Given that, according to the CDC, only 715,000 of those deaths occur in hospitals, if Makary and Daniel’s numbers are to be believed, some 35% of inpatient deaths are due to medical errors. That’s just one reason why there are a lot of problems with this article, but there are even more problems with how the results have been reported in the press and the recommendations made by the authors." Read the 400+ comments!
• Do No Harm: Stories of Life, Death, and Brain Surgery by Henry Marsh. What is it like to be a brain surgeon? How does it feel to hold someone’s life in your hands, to cut into the stuff that creates thought, feeling and reason? How do you live with the consequences of performing a potentially lifesaving operation when it all goes wrong? Leading neurosurgeon Henry Marsh reveals the fierce joy of operating, the profoundly moving triumphs, the harrowing disasters, the haunting regrets and the moments of black humor that characterize a brain surgeon’s life. See also Admissions: A Life in Brain Surgery And Anatomy of Error (Joshua Rothman, New Yorker, 5-18-15) A review of Dr. Marsh's book Do No Harm: Stories of Life, Death, and Brain Surgery, a review that in itself explains a few things also.
• Superficial coverage of medical errors could leave erroneous impression with readers (Kevin Lomangino, Health News Review, 5-6-16) "...But the problems run deeper than ambiguous headlines. As the blogger known as Skeptical Scalpel (a self-described former chairman of surgery) points out, the BMJ paper takes some pretty big leaps to come up with its new national total for error-related deaths. And the idea that all of these deaths are entirely preventable is also open to debate, he observes." See Are there really 250,000 preventable deaths per year in US hospitals? (Skeptical Scalpel, 5-5-16) "Whether a death is preventable or not is often subjective and may depend upon the completeness of records and the "hindsight bias" of the reviewers. ...Medical errors do occur, and they should be identified and prevented. Makary's essay shines no new light, only heat, on the subject."
• Medical Errors No. 3 Cause of Death in U.S. Candy Sagon, AARP, 5-4-16)"So what can patients do to protect themselves from medical errors? The nonprofit Hospital Safety Score has a number of good tips, including bringing a friend or family member along to ask questions and deal with problems, and making sure to ask about any type of medication you are given" (or treatment to pursue).''
• Hospital Ratings and Reports (The Leapfrog Group) How transparency is driving leaps forward in hospital care in this country. Hospitals across the country demonstrate their commitment to transparency and quality improvement through the Leapfrog Hospital Survey.
• (Excellence for Everyone, 2021 annual meeting) YouTube video, Leah Binder, Leapfrog Group, 34 min.) You can't have patient safety if you don't have patient equity.
• Dissecting Leapfrog: How Well Do Leapfrog Safe Practices Scores Correlate With Hospital Compare Ratings and Penalties, and How Much Do They Matter? (Shawna N. Smith, et al., Medical Care: June 2017 - Volume 55 - Issue 6 - p 606-614) "Conclusions: Voluntary Leapfrog SPS measures skew toward positive self-report and bear little association with compulsory Medicare outcomes and penalties. SPS significantly impacts HSS grades, particularly when lower SPS is reported. With increasing compulsory reporting, Leapfrog SPS seems limited for comparing hospital performance." For more on hospital evaluations, see What you need to know about hospitals--Report cards, watchdog reports, resources for finding critical information about hospitals and surgeons. Scroll down for SOURCES OF INFORMATION and REPORT CARDS ABOUT U.S. HOSPITALS.
• Hospital discharge: It’s one of the most dangerous periods for patients (Jordan Rau, Washington Post, 4-29-16) "Bad coordination often plagues patients’ transition to the care of home health agencies as well as to nursing homes and other professionals charged with helping them recuperate, studies show....“The most risky transition is from hospital to home with the additional need for home care services, and that’s the one we know the least about.” "...one of the most common complications for discharged patients. The federal government views them as “a major patient safety and public health issue,” and a Kaiser Health News analysis of government records shows such errors are frequently missed by home health agencies. Between January 2010 and July 2015, the analysis found, inspectors identified 3,016 home health agencies — nearly a quarter of all those examined by Medicare — that had inadequately reviewed or tracked medications for new patients. In some cases, nurses failed to realize that patients were taking potentially dangerous combinations of drugs, risking abnormal heart rhythms, bleeding, kidney damage and seizures." " Of the $30 billion that Congress appropriated to help shift the system to electronic medical records — to ensure better coordination of care and reduce errors across the board — none went to nursing homes, rehabilitation facilities or providers working with individuals in their homes."
• If not for flawed tracking, medical mistakes would be the third-leading cause of death, researchers at Johns Hopkins say. Study Urges CDC to Revise Count of Deaths from Medical Error ( Marshall Allen and Olga Pierce, Pro Publica, 5-3-16). Have You Been Harmed in a Medical Facility? Share your story with Pro Publica.
• Teaching a Martian to make a sandwich helps clinicians catch medical errors (Ike Swetlitz, STAT, 11-7-16) Anywhere between tens of thousands and hundreds of thousands of Americans, depending on whom you ask, die of medical errors each year. In programs designed to improve communication in ways that increase patient safety, innovative strategies are being tried. In one PhD program, "to teach students how challenging it is to communicate medical directions, students practice explaining how to make a peanut butter and jelly sandwich to an instructor pretending to be a Martian — someone who doesn’t have familiarity with basic English and the mechanics of peanut butter jars and bagged bread, said Donna Woods, an associate professor at the medical school who directs the PhD track. Invariably the student will write, ‘open the bag of bread,’” Woods said. “And so he rips the bottom rather than doing the little twist-tie thing.” This is meant to teach students that their directions might not be carried out as intended, which might lead to confusion or harm.
"Another exercise highlights doctor-patient communication, courtesy of Legos. The class splits up into teams to try to build the tallest building possible. But they also have to hew their designs to one member of the team — the 'customer' — who wants the building to look a certain way, perhaps to have a red base or a green spire. The customer is only to reveal their preferences if the rest of the team asks." These exercises are coupled with regular classes on research methods, so that students learn why the medical system is so complicated, and how they can work to make it better.
• My Father, Your Mother/Child/Cousin? Medical Mistakes Affect Millions Nationwide (Richard Knox, WBUR's CommonHealth Reform and Reality, 12-5-14)
Betsy Lehman, a Boston Globe health columnist, died 20 years ago as a result of a massive chemotherapy overdose given in error.
• 20 Tips to Help Prevent Medical Errors: Patient Fact Sheet (Agency for Healthcare Research and Quality)
• 10 Ways to Save Your Life or the Life of a Loved One (Jamie Leigh Wells, Huff Post, 5-3-16) Don't be complacent or allow yourself to be unduly influenced and make decisions based on minor inconveniences. Do things right the first time and systematically every time. Keep records in real time in a notebook by the bedside. Write down everyone who engages and when. Ask questions: What drug is that? Do not leave a family member alone in the hospital. Get copies of medical records as available. Have third party as objective observer; patients cannot absorb it all. The seemingly mundane tasks of coordinating details can be a tremendously significant and meaningful way to assuage fears and lighten the load. Interview caregiver.
• Eliminate the term "primary care provider." (JAMA article). Call them what they are: a physician assistant, a nurse, a doctor. Don’t swoon over an institution or “world-renowned” titles. (There are stinkers in the best of places, and people who make mistakes.) Encourage a reasonable and realistic continuity of care (not too many cooks in the kitchen). You are important: tell everything you know; know the name of every medication you take. Keep your own summary of your health in a concise front/back sheet to keep in wallet and make copies to give out to caregivers. "Include timeline that lists all name/contact information of physicians seen and for what, when started and stopped meds, recent & past medical history, family & social history, surgical history, allergies (food, drug, environmental exposure and reaction type), hospitalizations, ER visits (contact info) etc."
• Despite checklists, cataloging strategies and other efforts, ‘forgotten surgical items’ remain a problem (Cheryl Clark, Covering Health, Association of Health Care Journalists, AHCJ, 10-18-19) On Sept. 14, 1999, Dan Jennings' odyssey as a patient zero of medical errors began, and became a wake-up call for Clark, a journalist, who realized how easy it is for lapses in simple safety protocols to ruin lives. A metal retractor had been left behind in his abdominal cavity by surgeon Fred Hammill, at the end of a marathon day of 14 surgeries. By the time the problem was identified, damage was already done. Necrotizing fasciitis infection, which can occur when tissue reacts to metal, had plowed through Jennings’ intestines. What to call this type of error? "Retained foreign object" didn't capture the severity, so organizations began calling them forgotten surgical bodies. They were inserted and were supposed to be removed but teams of nurses and doctors forgot them.
• NoThing Left Behind: The Prevention of Retained Surgical Items Multi-Stakeholder Policy-Job Aid-Reference Manual (PDF, Dr. Verna Gibbs, professor of surgery at the University of California San Francisco)
• Twenty Years with a Retained Foreign Body after Hysterectomy: A Case Report. (Mashhadi MR, Shahabinejad M, Adv J Emerg Med., Summer 2019, on PubMed) Unintentionally retained foreign bodies (RFBs) can be accompanied with acute reactions such as inflammatory responses, infections and abscesses within a few days or weeks after surgery with adverse consequences for patients and surgeons.
• 10 Years After To Err Is Human: Are Hospitals Safer? (Cheryl Clark, Health Leaders, 11-30-09) Ten Years after the he Institute of Medicine's "To Err Is Human," the first of its 11-volume "Quality Chasm" series on improving patient care and avoiding mistakes, health providers were still noting about 98,000 preventable deaths a year. In many regions, facilities have not become "expert at looking for trouble. We're just learning to identify what harm is," said James Conway, senior vice president of the Institute for Healthcare Improvement in Cambridge, MA. This article mentions steps facilities should be taking.
• Forgotten surgical items: lessons for all to learn (Lenore Ellett, Peter Maher, Gynecological Surgery, 3-7-13) A 38-year-old woman with a fibroid uterus, causing unacceptable pressure symptoms, underwent a laparoscopic subtotal hysterectomy. 14 months later they removed a left-behind blue KOH cup attached to the cervix.
• California Fines 10 Hospitals $625,000 for Medical Errors (Health Leaders) Retained surgical objects, patient falls, and medication errors are the top violations leading to immediate jeopardy penalties issued to hospitals by the California Department of Health, bringing the total to $11 million dollars in penalties that 150 of the state's 400 hospitals have been told to pay.
• Retained Surgical Foreign Bodies after Surgery (Zejnullahu VA, Bicaj BX, Zejnullahu VA, Hamza AR. Retained Surgical Foreign Bodies after Surgery. Open Access Maced J Med Sci. 2017 Mar 15;5(1):97-100. PubMed.) The incidence of RSB is between 0.3 to 1.0 per 1,000 abdominal operations, and they occur due to a lack of organisation and communication between surgical staff during the process. Typically, the RSB are surgical sponges and instruments located in the abdomen, retroperitoneum and pelvis.
• Unintentionally Retained Foreign Objects: A Descriptive Study of 308 Sentinel Events and Contributing Factors (Victoria M. Steelman, et al., Joint Commission, Journal on Quality and Patient Safety, April 2019) "A total of 308 events involving URFOs were reported: instruments (102), catheters and drains (52), needles and blades (33), packing (30), implants (14), specimens (6), and other items (71). Many of the instruments were used in minimally invasive or orthopedic surgery. Items were most frequently retained in the abdomen or the vagina. Most URFOs occurred in the operating room. A total of 1,156 contributing factors were identified, most frequently in the categories human factors, leadership, and communication. In the majority of reports, the harm was categorized as unexpected additional care/extended stay. Five patients died as a result of the URFO."
• Seniors build strength, improve balance in fall prevention fitness class (CBC video, 2-2-18) Andrew Schindle works with seniors in Winnipeg on exercise classes that help them prevent falls and build strength. Worst problems: broken hip, head, and wrist injuries.
• An often-overlooked risk, the science of slips and falls can be life-saving (Kas Roussy, CBC News, 2-17-19) Falls-prevention experts turning to education and intervention to ensure 'every fall is not a disaster.' Students in a fall prevention class learn about the benefits of exercise, how to get up from a fall, stair safety, healthy eating and overcoming the fear of falling.
• Preventing falls, learning how to do them right, and getting up more easily after they happen (Pat McNees's roundup of advice) Practical advice and instructions.
• Live streaming dance class aims to help rural seniors avoid falls (Havard Gould, CBC News, 4-30-17) Ruth Snider, 65-year-old dance student, says she has 'much more control over my movements every day'
• Patient Safety Program (Agency for Healthcare Research and Quality, or AHRQ)
• Where have all the patient safety activists gone? (Cheryl Clark, Covering Health, AHCJ, 9-17-19) Mayer says too many hospital C-suite executives are not focused on improving patient safety. Instead, “they’re just out there trying to sell and gain more hospitals and market share, versus putting resources into correcting the existing product so it doesn’t hurt as many people as it does today.” The Institute for Healthcare Improvement (IHI) is trying to improve quality upstream, especially in skilled nursing facilities and ambulatory surgical centers. Diagnostic error is another patient safety issue now gaining attention, especially with the National Academy of Medicine’s 2015 report “Improving Diagnosis in Health Care” and the formation of the organization Society to Improve Diagnosis in Medicine, which holds a conference on the topic every fall. Patient safety and quality measurement also have suffered at the expense of the pressing need for reporters to focus on reducing health care costs and predatory billing, which is critically important, and improving health insurance access throughout the country.
• Federally listed patient safety programs (PSOs) (AHRQ)
• Patient Safety Action Network Community (a Facebook group)
• Consumer Safety Guide Recent information on the most popular prescription medications and FDA-approved medical devices that could be endangering your health or putting your loved ones at risk.
• Ways to Improve Electronic Health Record Safety (Pew Charitable Trusts, 8-28-18) Report: Rigorous testing and establishment of voluntary criteria can protect patients. You can download as PDF.
• The patient matching problem and ideas on how to solve it (Rebecca Vesely, Covering Health, AHCJ, 10-4-18) See 50-page report: Enhanced Patient Matching Is Critical to Achieving Full Promise of Digital Health Records (Pew, 10-2-18) Accurately linking individuals with their records essential to improving care. And archived video of panel discussion on the topic.
• Improving Patient Safety through Transparency (Allen Kachalia, NEJM, 10-31-13) Many institutions have initiated efforts to improve the sharing of information on publicly reported performance measures, but transparency regarding medical errors has proved much more difficult to achieve.
• 2018 Patient Safety Goals (The Joint Commission). See FAQs about Standards Interpretation.
• Latest Hospital Injury Penalties Include Crackdown On Antibiotic-Resistant Germs (Jordan Rau, Kaiser Health News, 12-21-16)
• A Visit to the Synthetic Cadaver Factory (Eric Grundhauser, Atlas Obscura, 5-2-17) Florida’s SynDaver Labs makes extraordinarily advanced anatomical models. See also this short video: A Glimpse Inside Florida's Cadaver Factory "Operating out of an unassuming office park in Tampa, Florida, is Syndaver Labs, a company in the business of making synthetic bodies. Syndaver creates realistic-looking tissues and organs out of material that’s little more than a special combination of water, salt, and other ingredients."
• Medical students are skipping class in droves — and making lectures increasingly obsolete (Orly Nadell Farber, STAT News, 8-14-18) "Nationally, nearly one-quarter of second-year medical students reported last year that they “almost never” attended class during their first two, preclinical years, a 5 percent increase from 2015. The AWOL students highlight increasing dissatisfaction and anxiety that there’s a mismatch between what they’re taught in class during those years and what they’re expected to know — or how they’re tested — on national licensing exams. Despite paying nearly $60,000 a year in tuition, medical students are turning to unsanctioned online resources to prepare for Step 1, the make-or-break test typically taken at the end of the preclinical years....Step 1, an eight-hour multiple choice test, is a big deal. Performance on the exam, though it’s taken before most students even begin training in a hospital, heavily influences which medical specialties they can eventually pursue after school and at what hospitals they can pursue them."
• SketchyMedical Harness the power of visual learning to ace the USMLE Step 1. One of the "unsanctioned online resources mentioned in previous item."
• 'Slips, Lapses, Fumbles': Medical Mistakes Kill, and a Solution Is Seen in Education (Karen Weintraub, WBUR, CommonHealth,7-18-18) Medical negligence kills more than 250,000 people, and harms about 10 times that number, every year. Pediatric geneticist Aubrey Milunsky, who spent 30 years practicing and teaching at the Boston University School of Medicine, thinks the solution should start with medical education.
• Doctors Reveal 12 Things No One Tells You About Pursuing a Career in Medicine (St. George's University) No. 4. You’ll need to decide on a specialty earlier than you think. Getting into medical school is no small feat. The MCAT and admissions process will likely dominate your thoughts for some time. But aspiring doctors need to also be thinking about long-term decisions, like which medical specialty you’d like to pursue.
• 6 Red Flags Medical School Isn't the Right Choice (Kathleen Franco, M.D., US News, 6-28-16) #1: If you have been unable to improve your MCAT score, think about the future and how many more times you will have to take standardized multiple-choice tests. Although many want these tests to disappear from medicine, it's unlikely that will happen anytime soon.
• A disturbing truth about medical school — and America’s future doctors (Brenda Sirovich, Wash Post, 5-8-17) "The trend toward near-exclusive reliance on standardized testing to measure educational achievement now extends all the way to medical school. Many may not realize that the readiness of aspiring doctors to enter the world of clinical medicine is now based overwhelmingly on a single, standardized, closed-book, multiple choice test....Such reliance on Board scores wasn’t always this way....We aim to prepare students for a career characterized by collaboration, complexity, nuance and uncertainty; yet, we evaluate them on their ability to select — autonomously and without research — among radio buttons representing a discrete range of right-or-wrong responses."
• What’s Wrong With Medical Education Today?(Lloyd I. Sederer, HuffPost, 10-5-10) "I was shocked, however, to learn that anatomy had been reduced to a mere eight weeks during the first year of medical school, instead of the full year that comprised my education 40 years ago. What’s more, those eight weeks now also included embryology and radiology — the logic for bundling these subjects together I could not understand nor did I ask. But eight weeks? How in the world could anyone dissect a cadaver in that time and actually learn about the human body?"
• Agency for Healthcare Research and Quality (AHRC) As 1 of 12 agencies within the Department of Health and Human Services, AHRQ supports research that helps people make more informed decisions and improves the quality of health care services.
• American Society for Health Care Risk Management (ASHRM) a professional membership group of the American Hospital Association (AHA) with nearly 6,000 members representing risk management, patient safety, insurance, law, finance and other related professions.
• Anesthesia Patient Safety Foundation (APSF) Mission: to improve continually the safety of patients during anesthesia care
• BeMedWise Program at NeedyMeds working to promote the wise use of medicines through trusted communication for better health. Was National Council on Patient Information and Education)
• California American Professional Society on the Abuse of Children (CAPSAC) One chapter of the American Professional Society on the Abuse of Children
• California Department of Public Health
• Collaborative Healthcare Patient Safety Organization (CHPSO) Created in 2008 by the California Hospital Association, CHPSO is a federally designated patient safety organization (PSO) dedicated to the elimination of preventable patient harm and improving the quality of health care delivery.
• Confident Voices in Healthcare "Safer, Kinder, Affordable, & Fair" Beth Boynton's professional blog focuses on making healthcare safer and more compassionate for everyone
• Health Care Innovations Exchange AHRQ created the Health Care Innovations Exchange to speed the implementation of new and better ways of delivering health care.
• Injured SeniorsFind Justice (Injured Senior Podcast) Senior Injury Hotline: 855-463-2306
• National Center for Patient Safety Home (VHA) Established in 1999 to develop and nurture a culture of safety throughout the Veterans Health Administration. Root Cause Analysis (RCA) is a multi-disciplinary team approach to studying health care-related adverse events and close calls.
• Patient Safety Action Network Community Guidelines (Facebook group)
• National Action Plan to Advance Patient Safety (Institute for Healthcare Improvement) Though many evidence-based, effective best practices related to harm reduction have been identified, they are seldom shared nationally and implemented effectively across multiple organizations. Reducing preventable harm requires a concerted, persistent, coordinated effort by all stakeholders, and a total systems approach to safety -- healthcare that is safe, reliable, and free from harm.
• National Patient Safety Goals (The Joint Commission)
• National Quality Forum (NFQ) NFQ's annual conference is the premiere event in healthcare quality and convenes the best and most innovative thinkers and leaders in public and private health, quality improvement, care delivery, healthcare policy, and technology.
• National Quality Measures Clearinghouse Part of AHRQ. NQMC is a public resource for evidence-based quality measures and measure sets.
• Partnership for Patient Safety (p4ps) A patient-centered initiative to advance the reliability of healthcare systems worldwide.
• Persons United Limiting Substandards and Errors (PULSE) Facebook health and wellness group)
Pat McNees wrote the following article for NIH Clinical Center News, September 2006. It appeared as "Expert explores the anatomy of medical error"
“Humans err,” said Dr. Saul N. Weingart, vice president for patient safety and director of the Center for Patient Safety at Dana-Farber Cancer Institute. “Training, communicating, and reminding are weak interventions,” said Weingart in a sweeping analysis of medical error, in a Grand Rounds lecture for NIH fellows in the Clinical Center last month. “Only by probing deeply can we understand the conditions that lined up to allow something unfortunate to happen. You’ve got to change the system.”
“Don’t rely on memory or vigilance,” said Weingart, “or expect people to perform well when fatigued.” Simplify routines, reduce handoffs, build in redundancies and provide better information. Create forcing functions (making it impossible to do action B without precondition A). Make use of best practices—bar coding, for example, and repeating verbal orders (“the Starbucks rule: I’d like a low-fat no-foam latte”).
Recognize missteps for what they are. Cognitive psychologists recognize three models of error in human performance; skill-based, rule-based, and knowledge-based. Human factor scientists call skill-based errors slips and rule-based and knowledge-based errors mistakes.
Skill-based behavior is rapid, effortless, unconscious—things you do automatically, such as brushing your teeth, buttoning your shirt, driving to work. Characteristic slips involve
· Capture (you’re supposed to do one sequence of steps, A,B,C,F, and instead you do ABCD, because ABCD is more common—as when you load up the family car for vacation and absentmindedly drive toward the office)
· Description error (correct action, wrong object—pouring syrup in your coffee or milk on your pancakes)
· Associative activation (having the wrong cue trigger a particular behavior—the doorbell rings and you answer the phone)
· Loss of activation (striding purposefully into a room and not remembering why you are there).
“These slips are common across all cultures,” says Weingart. “They are part of the human phenotype.” We’re built to perform many functions on an unconscious level so that we can think about other things that are more interesting and important. “But those automatisms allow us to get into trouble. And they are degraded by the things you’d expect, such as fatigue, illness, alcohol, sleep deprivation, and boredom.”
Rule-based behavior (when it’s raining, take an umbrella) is important in medical training. Using mnenomics, we train physicians in rule-based behaviors with code algorithms, said Weingart. “The trick is to apply it in the correct setting.” Rule-based mistakes occur when we apply the wrong rule — for example, going down a code algorithm but choosing the wrong arm.
Knowledge-based behavior involves solving novel problems, coming at them afresh. Knowledge-based mistakes, of which there are many, have to do with biased memory and intellectual convenience. We like to use the solution we used last time, or we don’t like to change our mind once we’ve come up with an initial hypothesis, or we’re overconfident about what we decide.
Knowing we are faulty machines and that errors are inevitable, said Weingart, we must design medical care systems that make those errors transparent and reduce the number of preventable adverse events and close calls—paying special attention to high-risk patients, “those with the least physiological reserve.”
It’s important, says Weingart, to take care of yourself, take care of the system, and reduce blame and shame. “If we’re not free to talk about errors,” he said, “we’ll never learn from them.”
Saul N. Weingart, MD, PhD, a national expert on reducing the prevalence and burden of medical error, is vice president for patient safety and director of the Center for Patient Safety at the Dana-Farber Cancer Institute and an associate professor at Harvard Medical School. He lectured in Lipsett Auditorium on August 2, 2006.
For a fuller discussion of the three models, see Lucius Leape, “Error in Medicine” JAMA, Dec. 21, 1994, 1851-57. See also:
Institute of Medicine report, Reducing Medical Errors
More stories about medical error and quality control
• Study Suggests Medical Errors Now Third Leading Cause of Death in the U.S. (Johns Hopkins Medicine, 5-3-16) Physicians advocate for changes in how deaths are reported to better reflect reality. 10 percent of all U.S. deaths are now due to medical error. Medical errors are an under-recognized cause of death.
• An Unexplained Injury Discovered After Eye Surgery. What Should Happen Next? (Fred Clasen-Kelly, KHN, 11-29-22) Some doctors and medical practices voluntarily give rebates on a bill if an injury occurs during a procedure, while others will not, an expert says. Patients are frequently left holding the bag for extended hospital stays and reparative treatments for events that are not their fault. Patients injured during a procedure can ask for a rebate or seek to have insurance copays waived, Caplan said. They can also file a complaint with a state medical board to try to find out what happened and whether professional standards were violated.
• Fact Sheet on Patient Safety (World Health Organization, 9-13-19) Globally, as many as 4 in 10 patients are harmed in primary and outpatient health care. Up to 80% of harm is preventable. The most detrimental errors are related to diagnosis, prescription and the use of medicines. Most people will suffer a diagnostic error in their lifetime. Medication errors are a leading cause of injury and avoidable harm in health care systems: globally, the cost associated with medication errors has been estimated at US$ 42 billion annually. Read article for more specific research findings.
No Prison Time for Tennessee Nurse Convicted of Fatal Drug Error (Brett Kelman, KHN, 5-13-22) RaDonda Vaught, a former Tennessee nurse convicted of two felonies for a fatal drug error, whose trial became a rallying cry for nurses fearful of the criminalization of medical mistakes, will not be required to spend any time in prison. Davidson County criminal court Judge Jennifer Smith on Friday granted Vaught a judicial diversion, which means her conviction will be expunged if she completes a three-year probation. In March she was convicted of criminally negligent homicide and gross neglect of an impaired adult for the 2017 death of 75-year-old patient Charlene Murphey. Murphey was prescribed Versed, a sedative, but Vaught inadvertently gave her a fatal dose of vecuronium, a powerful paralyzer.
• 'Slips, Lapses, Fumbles': Medical Mistakes Kill, and a Solution Is Seen in Education (Karen Weintraub, WBUR, CommonHealth,7-18-18) Medical negligence kills more than 250,000 people, and harms about 10 times that number, every year. Pediatric geneticist Aubrey Milunsky, who spent 30 years practicing and teaching at the Boston University School of Medicine, thinks the solution should start with medical education.
• 10 Medical Errors That Changed the Standard of Care (Medscape) Tragic and preventable errors dot the recent history of medicine; some were so glaring that they led to important changes in patient care.
• Over Half of Patients and Families Hesitate to Raise ICU Safety Concerns, Study Finds (Carey Goldberg, WBUR, CommonHealth, 7-16-18) A new study out of Beth Israel Deaconess Medical Center — the first ICU study of its kind — documents just how much families hesitate to speak up if they think they see a medical mistake being made. The researchers surveyed more than 100 family members in the ICU and more than 1,000 online about whether they'd feel comfortable speaking up about various concerns. Some didn't want to be labeled a troublemaker, some felt the team seemed too busy, some didn't know how or to whom to report their concern, and some didn't want to harm their "relationship with the members of the medical team...."On the flip side is that patients and families who don't speak up when there's a possible problem often end up carrying a lot of guilt if something does go wrong," said Dr. Sigall Bell of Beth Israel Deaconess Medical Center.
• A Trail of Medical Errors Ends in Grief, But No Answers (Marshall Allen and Olga Pierce, ProPublica, 12-18-15) Paula Schulte couldn't survive a cascade of medical mistakes. After that, her family couldn't get accountability.
• The Risks of Not Being Rested (Koren Thomas, Daily Nurse, Medpage today, 12-29-19) How nurses can make sure they get enough sleep.
• Researchers: Medical errors now third leading cause of death in United States (Ariana Eunjung Cha, WashPost, 5-3-16)
• I Was Suspended (Beth Hawkes, NurseCode.com, 1-6-18) I was suspended for a medication error as an RN. This is what I learned. (Read the comments, too.)
• Medical Errors, Past and Present (Dan Childs, ABC News, 11-27-07)
• A physician experiences a medical error. Here’s her story. (Maja Castillo, Kevin MD, Oct. 2016) Patients deserve health care without the worry of being harmed by the system itself.
• 3 horrific medical mistakes that scandalize the profession (Casey Flynn, Center for Health Journalism, 5-4-16) Preventable medical mistakes are the third leading cause of death in the U.S after heart disease and cancer. Here are stories about a brain surgery disaster at Rhode Island Hospital, Leilani Schweitzer's story about her son Gabriel (and a nurse who turned off an annoying alarm, and the child Alyssa Hemmelgarn's death because of medical errors in a Denver-area hospital.
• For Colorado mom, story of daughter's hospital death is key to others' safety (John Daly, Colorado Public Radio, 2-17-15) I had a 9-year-old daughter named Alyssa, and she was diagnosed with leukemia on a Monday and she died 10 days later,” said Carole Hemmelgarn.
• Hospital medication error kills patient in Oregon (CBS News, 12-4-14) A 65-year-old patient died shortly after she was given a paralyzing agent typically used during surgeries instead of an anti-seizure medication.
• 10 Nightmarish Stories About Terrifying Medical Errors (Gordon Gora, ListVerse, 1-30-16)
In its landmark 1999 report, The Institute of Medicine (the health arm of the National Academy of Sciences) identified the often fragmented aspects of hospital care and miscommunication at the patient hand-off as a point of potential tragedy. Its 1999 report, “To Err is Human: Building a Safer Health System" (read PDF here) challenged the age-old assumption that medical errors were basically an occasional, albeit unfortunate, result of medical treatment. At the time, an estimated 98,000 people a year died as a result of preventable medical errors -- which made medical errors the 8th leading cause of death in the United States, more than the number of people who died in car wrecks or from breast cancer or AIDS. (Adapted from MU leads national initiative to foster a new culture of health care teamwork .)
The IOM report To Err Is Human:Building a Safer Health System, presented a strategy by which government, health care providers, industry, and consumers could reduce preventable medical errors. This report led to several others, which an educated consumer could use as a checklist on how not to be the victim of hospital-caused medical problems (above all, make sure whoever does a procedure on you washes their hands first).
In February 2000, the Quality Interagency Coordination Task Force (QuIC) issued a report, Doing What Counts for Patient Safety: Federal Action to Reduce Medical Errors and Their Impact, listing more than 100 activities needed to:
1. Create a national focus on reducing errors.
2. Develop a knowledge base for learning about errors' causes and effective error prevention.
3. Ensure accountability for safe health care delivery.
4. Guarantee that patient safety practices are implemented.
The Institute for Healthcare Improvement (IHI) announced the 100k lives Campaign, through which healthcare organizations, by implementing one or more of six specific evidence-based practices, could join a campaign to potentially prevent 100,000 avoidable deaths. Six interventional measures were identified as crucial to improving patient safety:
* Deploying rapid response teams at the first sign of patient decline.
* Delivering reliable, evidence-based care for acute myocardial infarction (AMI) to prevent deaths from heart attack (for example, give patient an aspirin).
* Preventing adverse drug events (ADE) by implementing medication reconciliation.
* Preventing central line infections by implementing a series of scientifically grounded interdependent interventions.
* Preventing surgical site infections by reliably delivering appropriate antibiotics and other specific steps.
* Preventing ventilator-associated pneumonia by implementing a series of scientifically grounded interdependent interventions.
To this it added new interventions targeted at harm
* Prevent harm from high-alert medications... starting with a focus on anticoagulants, sedatives, narcotics, and insulin
* Reduce surgical complications... by reliably implementing all of the changes in care recommended by SCIP, the Surgical Care Improvement Project (www.medqic.org/scip)
* Prevent pressure ulcers... by reliably using science-based guidelines for their prevention
* Reduce methicillin-resistant Staphylococcus ureus (MRSA) infection…by reliably implementing scientifically proven infection control practices
* Deliver reliable, evidence-based care for congestive heart failure... to avoid readmissions
* Get Boards on board … by defining and spreading the best-known leveraged processes for hospital Boards of Directors, so that they can become far more effective in accelerating organizational progress toward safe care
• Medicare Cuts Payment to 774 Hospitals Over Patient Complications (Jordan Rau, Kaiser Health News,2-19-21) The federal government has penalized 774 hospitals for having the highest rates of patient infections or other potentially avoidable medical complications. Those hospitals, which include some of the nation’s marquee medical centers, will lose 1% of their Medicare payments over 12 months. The penalties, based on patients who stayed in the hospitals anytime between mid-2017 and 2019, before the pandemic, are not related to covid-19. They were levied under a program created by the Affordable Care Act that uses the threat of losing Medicare money to motivate hospitals to protect patients from harm.
• Silence Kills: Speaking Out and Saving Lives , edited by Lee Gutkind (essays about communication failures that lead to potentially lethal medical error)
ECRI Institute Announces Top 10 Health Technology Hazards for 2015 . Alarm hazards, electronic health record data integrity issues, and infusion line mix-ups top the list, available now for free download.) Topics on the 2015 list include:
1. Alarm hazards: Inadequate alarm configuration policies and practices
2. Data integrity: Incorrect or missing data in electronic health records and other health IT systems
3. Mix-up of IV lines leading to misadministration of drugs and solutions
4. Inadequate reprocessing of endoscopes and surgical instruments
5. Ventilator disconnections not caught because of mis-set or missed alarms
6. Patient-handling device use errors and device failures
7. “Dose creep”: Unnoticed variations in diagnostic radiation exposures
8. Robotic surgery: Complications due to insufficient training
9. Cybersecurity: Insufficient protections for medical devices and systems
10. Overwhelmed recall and safety alert management programs
.Many websites and reports deal with improving patient safety and hospital staff performance. A quick look at those lists will give you a checklist of things to watch for when you or a loved one checks into a hospital. For one thing, you'll make sure healthcare providers wash their hands between patients and activities!
• The Checklist (Atul Gawande, The New Yorker, 12-10-07). If something so simple as a checklist can transform intensive care, what else can it do? In 2001, a critical-care specialist at Johns Hopkins Hospital named Peter Pronovost designed a checklist of steps to take to prevent a line infection in the intensive care unit. He asked the nurses in ICU to observe the physicians for a month using these checklists. "In more than a third of patients, they skipped at least one." Medical staffs resisted such checklists, until there were incentives to use them, such as higher reimbursement from insurance.
To avoid infections when putting a line in. Doctors are supposed to
(1) wash their hands with soap,
(2) clean the patient’s skin with chlorhexidine antiseptic,
(3) put sterile drapes over the entire patient,
(4) wear a sterile mask, hat, gown, and gloves, and
(5) put a sterile dressing over the catheter site once the line is in.
Watch to see if your doctor does that.
• 15 Steps for Protecting Patients (RID, Reducing Hospital Infections)
These include (the first six):
1. Ask that hospital staff clean their hands before treating you, and ask visitors to clean their hands too. This is the single most important way to protect yourself in the hospital.
2. If you're visiting someone in the hospital, instead of bringing candy bring a canister of bleach wipes to wipe down surfaces around the bed, including bedrails, call button, and television controls.
3. "If you need a “central line” catheter, ask your doctor about the benefits of one that is antibiotic-impregnated or silver-chlorhexidine coated to reduce infections."
4. "If you need surgery, choose a surgeon with a low infection rate. Surgeons know their rate of infection for various procedures. Don't be afraid to ask for it."
5. "Beginning three to five days before surgery, shower or bathe daily with chlorhexidine soap. Various brands can be bought without a prescription. It will help remove any dangerous bacteria you may be carrying on your own skin."
6. "Ask your surgeon to have you tested for methicillin-resistant Staphylococcus aureus (MRSA) at least one week before you come into the hospital. The test is simple, usually just a nasal swab. If you have it, extra precautions can be taken to protect you from infection."