MEDICAL ERROR: an act of omission or commission in planning or execution that contributes or could contribute to an unintended result (Grober, Bohnen, 2005).
Near miss: any event that could have had an adverse patient consequence but did not, and was indistinguishable from a full-fledged adverse event in all but outcome (Grober, Bohnen, 2005).
Negligence: failure to meet the standard of care reasonably expected of an average physician qualified to take care of the patient in question (Grober, Bohnen, 2005).
Adverse event: unintended injury to patients caused by medical management (rather than the underlying condition of the patient) that results in measurable disability, prolonged hospitalization or both (Grober, Bohnen, 2005).
Malpractice as legally defined requires three elements: the recognized standard of care was not met, harm was done to the patient, and that harm resulted from the failure to meet the standard of care (Zientek, 2010).
TYPES OF ERROR: There are two types of error reported which are discussed below:
1.(a) execution: the error in which a medical action is not carried out as planned, for instance, dispensing a different medication from the one ordered).
1.(b) planning: the errors in which the choice of the action to be undertaken is incorrect for the desired result such as prescribing antibiotics for treatment of heart failure (Zientek, 2010).
1.(c) Reason divided errors into three forms:
1c).I Skill-based: Drug errors
Forget to switch ventilator on
Forget to hand ventilate
1.(c)ii Rule-based: Volatile not turned off during arrests
No anaesthetic machine check
Failure to implement ACLS guidelines
Inadequate recall of management guidelines for anaphylaxis
1.(c)iii Knowledge-based: Situational awareness failure (e.g. blood loss)
Not projecting course of situation such as anaphylaxis (Mallory, Weller, Bloch and Maze, 2003).
4.Reason’s Swiss Cheese Model of medical errors:
Clinical environment has a number of safeguards to prevent errors. The routinely safeguards include pre-operative assessment, consent form, anesthetic machine check, oxygen failure alarms, and regulation of opioid medication postoperatively. However, each level of defense is vulnerable. When a hole in it develops, the propagation of the error should be preventable at a subsequent level. It is when these ‘holes’ line up, level upon level, due to a series of circumstances, that adverse outcomes are produced. We should aim to identify these ‘holes’ in order to strengthen defences against errors.The holes in the safety mechanisms within a system arise via two different routes. Firstly, there are ‘active failures’.These are errors by a person. However, an adverse outcome is rarely due to a single error. The system also contains ‘latent errors’. These are the ‘accidents waiting to happen’, the intrinsic flaws in the system that may come to light in a particular set of circumstances. Removing the individual will do little to reduce the chance of that error recurring. However, addressing the underlying latent errors in the system may prevent error and arrest its evolution (Mallory, Weller, Bloch and Maze, 2003).
The model by Reason indicates that the preferred strategy is either to prevent an error from occurring or prevent the error from causing harm through the application of multiple steps that function as a safety net. High-technology systems, such as the OR, have levels of defense to catch errors or prevent them from occurring and causing harm, including the surgical safety checklist, the surgical team, and policy and procedures.
2.Mechanism
2.(a)Identification of error: The patient or family should be notified once error is identified and a system should be in place to review the events surrounding the error along with recommendations for appropriate changes at the same time (Zientek, 2010).
2.(b) Investigation of error: Then the involved institution should investigate the nature of the error leading to recommendations so that future risk to patients can be avoided.
2.(c) Make an apology: The effective apology has four parts which are described below:
2.(c)i Confessing the injury made to the patient or family with the recognition of the responsible party and should admit occurred the event as unacceptable.
2.(c)ii Explanation for the reason that lead to error.
2.(c)iii Expression of remorse, shame, forbearance (the commitment not to repeat the error), and humility. The involved institution should describe the steps that will be undertaken to change the system that caused the error.
2.(c)iv The last element of apology includes reparation which may include allocating corrective care at no cost or a financial settlement (Zientek, 2010).
3. Impact
3.(a) Second victim: The emotional distress can be intense for the health care provide and subject to feelings of shame and psychological stress due to the fear of legal action by the injured patient. Nurses have the additional fear of losing their job if they are involved in or on reporting error (Zientek, 2010). Second victims include physicians, nurses, or other health care providers who suffer mental and emotional distress from being involved in a medical mistake (Robertson 2018)
4.Prevention and management of medical error:
4.(a) human factors: Restricting the medical professionals working hours.
4.(b) Availability of information: The information model assumes that the delivery of the “right information, to the right people, at the right place and time” can prevent errors. The introduction of information and communication technologies (ICTs)has been advocated to implement solutions to medical error management (YEE, WONG, TURNER 2006).
4.(c) create leadership and research tools to enhance the knowledge base about patient safety
4.(d) Extensive team-training exercise across hospitals to alter processes and thereby embed patient safety into hospital culture (Oyebode 2013).
4.(d) The use of voice-recognition technology for radiology reports (Oyebode 2013).
4.(e) The use of electronic prescribing and information technology systems (Oyebode 2013).
4.(f) The participation of a pharmacist (as a member of the clinical team) on clinical rounds also reduces the chances of adverse drug events (Oyebode 2013).
4.(g) The use of computer-based protocol reminders appears to improve the patient safety
4.(h) Computer-assisted decision-making helps the medical professionals (Oyebode 2013).
4.(I) Bar coding, smart pumps and computerized error monitoring also contribute in improving patient safety (Oyebode 2013).
4.(j) Fill the educational gap between doctors and nurses and train staff in these vital areas that often result in errors (MACKLES, ARNOLD, 2017).
4.(k) “Read-back” and “Repeat-back”: When physicians give in-person verbal or telephone orders then the nurse answering the phone call simply repeats it back to make sure that it was heard correctly (MACKLES, ARNOLD, 2017).
4.(l) The teach-back method: It can be applied in conversations between health care providers and patients to confirm understanding (MACKLES, ARNOLD, 2017).
4.(m) The CUS tool: This tool enables nurses and doctors to communicate on the same wavelength. The three specific words used to describe clinical situations of increasing severity are concern, uncomfortable, and safety (MACKLES, ARNOLD, 2017).
4.(n) SBAR and I-Pass system for handoffs: The S is the patient’s situation, B is the patient’s background, A is assessment, and R is recommendations. I-Pass system includes the electronic medical record, and a computer-generated handoff worksheet produced at handoff time (MACKLES, ARNOLD, 2017).
5CAUSES:
5.(a) Nursing fatigue: Current work practices with excessively long hours due to inadequate medical handovers are incompatible with safe healthcare delivery (MACKLES, ARNOLD, 2017). Working long shifts, night shifts and rotating shifts, as well as mandatory or voluntary overtime contributes to nursing fatigue ultimately leading to medical errors (Brown 2016).
5.(b) Leadership: even without the specific training, leadership allows a nurse to work in a special unit because of shortage of nursing. Thus, the chances of administering a high-risk medication via an inappropriate route increases which cause significant patient harm.
5.(c) Communication Pitfalls: It includes inappropriate orders that are unclear, illegibly written or not within the standard of care (Brown 2016).The failure of inclusion of the daily medication of the patient in the discharge medication list while transferring a patient to other hospital.
5.(d) Assessment: Delay in examination of patient may lead to serious medical conditions.
5.(e) Educational gap: the significant gaps in the classical education and training of doctors and nurses lead to medical errors. Medical schools focus on the basics of diagnosis and treatment, while nursing programs educate on patient evaluation, nursing care, and the skills necessary to carry out treatment plans (MACKLES, ARNOLD, 2017).
Reference :
Oyebode, F. (2013). Clinical errors and medical negligence. Medical Principles and Practice, 22(4), 323-333.
http://eds.a.ebscohost.com.libaccess.fdu.edu/ehost/pdfviewer/pdfviewer?vid=18;sid=a116caeb-3a3d-41e2-954a-e085d4d6543e%40sessionmgr4007
Zientek, D. M. (2010, June). Medical error, malpractice and complications: a moral geography. In HEC forum (Vol. 22, No. 2, pp. 145-157). Springer Netherlands.
https://search-proquest-com.libaccess.fdu.edu/docview/743823535?accountid=10818
Grober, E. D., ; Bohnen, J. M. (2005). Defining medical error. canadian Journal of Surgery, 48(1), 39.
http://eds.a.ebscohost.com.libaccess.fdu.edu/ehost/pdfviewer/pdfviewer?vid=16;sid=a116caeb-3a3d-41e2-954a-e085d4d6543e%40sessionmgr4007
Anderson, J. G., ; Abrahamson, K. (2017). Your Health Care May Kill You: Medical Errors. In ITCH (pp. 13-17).
http://eds.a.ebscohost.com.libaccess.fdu.edu/ehost/pdfviewer/pdfviewer?vid=9;sid=a116caeb-3a3d-41e2-954a-e085d4d6543e%40sessionmgr4007
Yee, K. C., Wong, M. C., ; Turner, P. (2006). Medical error management and the role of information technology–a new approach to investigating medical handover in acute care settings. Studies in health technology and informatics, 124, 679-684.
http://eds.a.ebscohost.com.libaccess.fdu.edu/ehost/pdfviewer/pdfviewer?vid=7;sid=a116caeb-3a3d-41e2-954a-e085d4d6543e%40sessionmgr4007
Mallory, S., Weller, J., Bloch, M., ; Maze, M. (2003). The individual, the system, and medical error. Continuing Education in Anaesthesia, Critical Care ; Pain, 3(6), 179-182.
https://www-sciencedirect-com.libaccess.fdu.edu/science/article/pii/S1472261517300158
Robertson, J. J., ; Long, B. (2018). Suffering in Silence: Medical Error and its Impact on Health Care Providers. Journal of Emergency Medicine, 54(4), 402-409.
https://www-sciencedirect-com.libaccess.fdu.edu/science/article/pii/S0736467917311678?_rdoc=1;_fmt=high;_origin=gateway;_docanchor=;md5=b8429449ccfc9c30159a5f9aeaa92ffb
Brown, G. (2016). Averting Malpractice Issues in Today’s Nursing Practice. The ABNF journal: official journal of the Association of Black Nursing Faculty in Higher Education, Inc, 27(2), 25-27.
http://eds.a.ebscohost.com.libaccess.fdu.edu/ehost/pdfviewer/pdfviewer?vid=8&sid=36912689-613a-4644-931d-82f72e7ec6f4%40sessionmgr4006
