Patient Safety and Quality Improvement: Medical Errors and Adverse Events

Abstract

1. Michael S. Leonard, MD, MS* 1. *Chief Quality & Safety Officer for Children's Services, Associate Professor of Pediatrics, University of Rochester Medical Center, Rochester, NY. After completing this article, readers should be able to: 1. Define terms commonly used in patient safety discourse. 2. Describe the scope of medical errors and adverse events, focusing on medication-related issues. 3. Identify barriers to improving patient safety. 4. Address disclosure of medical errors and adverse events. 5. Review principles and practices that can reduce the risk of harm to patients. This is the first in a series of articles to review the topics of patient safety and quality improvement in pediatrics. Patient safety is a subject that traverses all medical specialties and affects every health-care professional. The attention to medical errors and adverse events as well as the resultant literature has grown exponentially over the past decade. A number of practicing physicians, however, remain unaware of the extent of the problem, the impact on patients, and the burden on the health-care system. Many also are unfamiliar with strategies to reduce the risk of harm. It is important to note that definitions used in patient safety can vary across studies, between organizations, and over time. A medical error, as defined by the Institute of Medicine (IOM), is “the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim.” (1)(2) It is a mistake in action or judgment. A medical error must be distinguished from an adverse event, which is “an injury caused by medical management rather than by the underlying disease or condition of the patient.” An adverse event results in harm to the patient. Not all medical errors lead to adverse events. In fact, most do not. A medication error is the most common …