Death by Medical Error: A Team Approach to Resolution
Most people are familiar with the common causes of death among Americans, such as heart disease, stroke, accidents, respiratory disease, and cancer. However, there’s another cause that makes the list, and it might surprise even healthcare professionals — medical errors.
As a matter of fact, a 2016 study from John Hopkins Medicine reports, “new data reveals medical errors are the third cause of death in the United States.” This means thousands of deaths a year could be prevented by improving our approach to diagnosis and treatment.
Another unfortunate factor in regards to medical errors and injury is that the physician and their medical team (nurses, interns, etc.) tend to carry the blame when fault often lies with healthcare systems. With this in mind, MedCognition is addressing the main causes of medical errors and offer suggestions that could help us prevent them in the future.
Common Causes of Medical Errors
Medical errors are bound to occur because the healthcare industry is operated by humans and humans make mistakes, but we can significantly reduce errors by being aware of the most common causes of healthcare mistakes.
Pharmaceutical dosing is one of the major areas of medical error that may have some of the most devastating outcomes. A 2017 report from the FDA states:
Since 1992, the Food and Drug Administration has received nearly 30,000 reports of medication errors. These are voluntary reports, so the number of medication errors that actually occur is thought to be much higher.
You might also remember in 2007, actor Dennis Quaid and his wife Kimberly’s newborn twin girls were given an overdose of heparin. Although the girls survived the overdose, the incident brought much attention to the prevalence and dangers of pharmaceutical errors.
Whether it’s failing to pass along critical information during patient transfers or clear and regular communication among the healthcare team, poor communication is one of the main reasons medical errors occur. In one study, a 2016 medical journal found over a third of pediatric residents cited faulty communication as a significant cause of medical error.
Medical professionals are often balancing work and home-life, college and work, or working several hours in a row. As a result, a lack of quality sleep among medical professionals is common. Furthermore, sleep deprivation interferes with memory retention, decision making, and many other cognitive and bodily functions.
Although we would like to think the people overseeing our health are 100% present and alert, the truth is no one suffering from fatigue is at their best which leaves room for medical errors to occur. The U.S. Department of Health and Human Services has featured several studies that link fatigue and sleep deprivation to medical errors.
FAILURE TO REPORT MEDICAL ERRORS
No medical professional wants to make mistakes that harm or nearly harm a patient, but it is crucial that we report medical errors. Failure is one of the fastest ways we learn. Moreover, when a medical mistake is made, the team can assess the cause and how to avoid it in the future.
Unfortunately, holding physicians or their residents accountable for mistakes is one of the reasons they hesitate to report medical errors. A 2016 study found:
Of the 130 postgraduate residents, 103(80%) disclosed the medical error to someone. Those who discussed their error with the senior physician involved in the case were only 73(57%), disclosure to none was 27(21%) and least number of residents 15(11%) disclosed the error to the patient’s family.
Very little data is available that shows the relationship between cognitive biases and medical errors, but our biases may cause us to make diagnoses and management mistakes. BioMed Central’s 2016 article on cognitive biases and medical decisions which analyze several studies on cognitive biases and medical errors, contends that all the studies they assessed found at least one cognitive biases or personality trait affected physicians’ medical decisions.
A System Approach to Resolution
Contrary to popular belief, medical errors rarely occur because of one person’s mistakes and instead are often the result of inadequate systems. According to a 2009 article in Clinica Chimica Acta, “In 2000, the Institute of Medicine published a study on medical errors that reports medical errors cause 98,000 deaths every year, and those deaths are related to incompetent healthcare systems not incompetent people.”
This means changing healthcare systems could reduce the prevalence of medical mistakes and prevent thousands of deaths a year. Furthermore, by taking the blame off people and approaching medical errors as a team, we direct our focus to fix the problem instead of placing fault.
Several studies have shown changes to the following systems have significantly reduced the occurrence of medical errors:
- Healthcare takes a team: When it comes to diagnosing and treating patients, a team approach is the best solution. Even involving the patient and their loved-ones in managing their healthcare can make a difference in the quality and accuracy of their care.
- A culture that fosters safety: A workplace environment that fosters safety can greatly decrease medical errors. In this approach, the team focuses on the patient’s safety, meaning the patient has more than one advocate to speak for their health.
- Communication: Teams must be taught to discuss on a regular basis the patient’s medications, history, lab tests, therapies, and so forth. Healthcare facilities should also consider implementing a handoff program which has been linked to reducing medical errors and preventing adverse events while improving communication without negatively affecting workflow according to a 2014 study from The New England Journal of Medicine.
- Unit dosing and computerized physician order entry system (CPOE):
- Unit dosing: a system where the pharmacist provides every medication to the nurse in the correct dose and form. This system according to Clinica Chimica Acta “nearly completely eliminates dosing errors.”
- CPOE: “the physician must enter all orders, including all prescriptions for medications, by computer. This ensures that the order is complete, it is not a medication the patient is allergic to, and that the dose is within usual limits. Studies show that CPOE can reduce serious medication errors by 60–80%,” states Clinica Chimica Acta.
- Encourage reporting: Healthcare professionals fail to report mistakes for several reasons, making it difficult to learn and prevent the same mistakes from occurring. We must encourage medical error reporting, so we can learn from our errors and create a more competent healthcare system.
Medical errors have devastating effects on everyone involved, they can harm or cause death to a loved one as well as have unfavorable psychological and emotional effects on the medical staff. At MedCognition, we believe the solutions to these issues are making everyone more aware of medical errors and changing healthcare systems to promote safer diagnoses and treatment.
- BioMed Central: Cognitive Biases Associated with Medical Decisions: a Systematic Review
- Clinica Chimica Acta: Errors in Medicine
- Food and Drug Administration: Strategies to Reduce Medication Errors: Working to Improve Medication Safety
- John Hopkins Medicine: Study Suggests Medical Errors Now Third Leading of Death in the U.S.
- Pakistan Journal of Medical Sciences: Medical Errors; Causes, Consequences, Emotional Response, and Resulting Behavioral Change
- The New England Journal of Medicine: Changes in Medical Errors after Implementation of a Handoff Program
- U.S. Department of Health and Human Services: Fatigue, Sleep Deprivation, and Patient Safety
WRITTEN BY HECTOR CARABALLO AND BRANDY VICKERY
Hector Caraballo, MD is a practicing Board Certified Emergency Physician and Chief Medical Officer at MedCognition.
Brandy Vickery is a professional medical writer with a degree in Health Administration and is currently earning a degree in English Creative Writing. She enjoys writing about medical technology, processes, and concepts that improve the healthcare industry for everyone.