According to the Institute of Medicine publication, To Err is Human: Building a Safer Health System, error is "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim." In an "error of execution", the correct action does not proceed as intended. When the intended action is not correct, this is an "error of planning".
Preventable adverse events, otherwise known as "sentinel events", cause an injury to a patient as a result of medical intervention or inaction on the part of the healthcare provider, where the injury cannot reasonably be said have caused the patient's underlying medical condition.
Medical malpractice counsel are not, as lawyers, in the business of preventing injury from medical error. However, as consumers in a healthcare system, lawyers and their families have a vested interest in seeing the present unacceptable rates of medical error reduced.
Promoting error reduction is also consistent with improved litigation efficacy. Plaintiff counsel have traditionally focused on litigating the avoidable errors, but there is a supplementary approach that is largely uncharted territory.
Although medical error is common and inevitable, tools exist for detecting errors before they do the worst of their damage. Some of these instruments have been tested and have proven not only to detect and mitigate medical error but also to be highly cost-effective in the long-term.
Failure to adopt such error-detection systems is arguably negligent.
No cost is involved in the simple and effective expedient of requiring nurses to read back orders that they have just taken verbally1.
Practice PointFor errors in taking verbal orders, establish whether the hospital has a protocol for mandatory read-back |
Adverse Drug Events (ADEs) affect 2-7% of hospital inpatients and kill or injure 3 per thousand of the population annually2, Rather more than a quarter of ADEs are caused by the prescription, dispensing and administration of medications, and are therefore preventable. Written prescription orders are susceptible to frequent and common errors. CPOE detects and significantly reduces3 the frequency of injurious medication error.
Practice PointComputerized Physician Order Entry detects and prevents medication errors arising from
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Insulin that is inadvertently administered to a non-diabetic can cause permanent brain damage or be lethal if the error is not detected promptly. Incidents in which the right drug is given to the wrong patient can be largely avoided by matching bar codes on unit-dose drugs and the patient's wrist-band4. This technology has been standard for many years for retail store check-out and inventory. In conjunction with lap-top computers, bar coding could usefully have long been standard in hospital drug administration.
Practice PointHospitals should be held accountable for not introducing bar-coding to detect and prevent drug administration to the wrong patient |
Preliminary study of interventions by a pharmacist during rounds on a teaching hospital medical unit suggests that many errors of dosing and medication frequency can thereby be spotted5.
Even when procedural errors are observed by other health professionals, they are unlikely to be reported to the team caring for the patient6. On occasions, the injured patient and/or family members know that another caregiver spotted an error but did not report it to the attending physician or nurse in timely fashion.
By contrast, formal teaching of an aviation industry model of team behaviours to Emergency Department staff resulted in a material increase in error detection7.
Leaders in Risk Management are formalising thorough investigation of the systemic causes of adverse events and near misses8. In contrast with industries in which errors are readily acknowledged, analysed and thereby avoided in the future, quality assurance, clinico-pathological conferences and peer-review more generally tend to be perfunctory and knee-jerk in their approach.
Practice PointIf a similar error is known to have previously occurred to a different patient in the same hospital, establish what was done to identify and correct the systemic causes |
Copyright © 2009 Electronic Handbook of Legal Medicine