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.

Portrait of frustrated medical doctor woman

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

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.

POOR COMMUNICATION

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.

FATIGUE

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.

COGNITIVE BIASES

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:

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.  


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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.