Medical Mishaps Research Articles

Responding to Large-Scale Testing Errors: Table 1

Extensive use of automation in the clinical laboratory creates the potential for systematic errors that affect a large number of patient results before the error is discovered. When a large-scale testing error is found, the approaches recommended for responding to individual medical mishaps are often inadequate. This report uses 2 case studies to illustrate some of the unique challenges facing laboratory managers confronted with a large-scale testing error. We identify 9 distinct constituencies that may be impacted by large-scale testing errors, each of which requires laboratory management's thoughtful and timely attention.

Three Cases of Correctional Litigation: Learning From the Root Causes

In correctional settings, deviations from the standard of care are not self-correcting as they would be for free persons who may request different opinions or change providers. Inmates are perceived as generally litigious and may file suits with frequency. The author analyzed three typical cases of correctional litigation. The allegations were failure to work up hemoptysis in a patient with asthma, leading to delays in the diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) pneumonia and death; failure to continue antiretroviral therapy (ART) plus failure to implement emergency treatment with antivirals specific for opportunistic infections of the eye, resulting in blindness; and failure to timely diagnose rhabdomyolysis with ensuing need for renal dialysis and accidental perforation of the vena cava and death. Analysis of the root causes led to the development of risk management techniques aimed at preventing medical mishaps and avoiding litigation.

Mitigation of Medication Mishaps via Medication Therapy Management

In 2006, the Center for Medicare & Medicaid Services incorporated the requirement for a Medication Therapy Management Program (MTMP) for individuals with Part D coverage to ensure that drug regimens provide optimal therapeutic outcomes through improved medication use, thereby reducing adverse drug events. To evaluate the effectiveness of an MTMP implemented for Medicare Advantage Prescription Drug members enrolled with Health Alliance Plan (HAP) during 2006 and 2007. Patient eligibility for MTMP was searched electronically. Clinical pharmacists researched medication histories and adherence and, through telephone contact, ascertained the patients' healthcare goals and needs. A patient-centered pharmacotherapy plan was created and implemented collaboratively with the patient's physician(s). To ensure that therapy goals were met, pharmacists performed follow-up interventions. Clinical outcomes and cost savings were compared for MTMP enrollees versus those declining enrollment. Average enrollment rate for the MTMP was 20% for 2006 and 2007. Nearly 60% of interventions involved changing therapy to improve efficacy and greater than 40% involved changing therapy to improve safety. Analysis of 2006 data revealed an overall improvement in electronically measurable clinical outcomes for MTMP enrollees versus individuals who declined enrollment, including a trend toward improved adherence to drug therapy for heart failure, insulin use, and a significant reduction in gastrointestinal bleeds (p = 0.001). Cost-savings analysis indicated a greater reduction in total prescription per member per month costs ($PMPM) of 17.2% for MTMP enrollees versus a 7% reduction for those who declined MTMP (p = 0.001). Patients who enrolled into the 2006 MTMP also saw a sustained positive effect in lowered $PMPM for prescription drugs in 2007. The HAP MTMP, conducted through telephone contacts, produced positive trends in improving clinical outcomes, reductions in pharmacy costs, and sustained pharmacy cost savings for patients who enrolled in the MTMP compared with patients who declined enrollment.

Use of High Fidelity Operating Room Simulation to Assess and Teach Communication, Teamwork and Laparoscopic Skills: Initial Experience

Structured opportunities for learning communication, teamwork and laparoscopic principles are limited for urology residents. We evaluated and taught teamwork, communication and laparoscopic skills to urology residents in a simulated operating room. Scenarios related to laparoscopy (insufflator failure, carbon dioxide embolism) were developed using mannequins, urology residents and nurses. These scenarios were developed based on Accreditation Council for Graduate Medical Education core competencies and performed in a simulation center. Between the pretest scenario (insufflation failure) and the posttest scenario (carbon dioxide embolism) instruction was given on teamwork, communication and laparoscopic skills. A total of 19 urology residents participated in the training that involved participation in at least 2 scenarios. Performance was evaluated using validated teamwork instruments, questionnaires and videotape analysis. Significant improvement was noted on validated teamwork instruments between scenarios based on resident (pretest 24, posttest 27, p = 0.01) and expert (pretest 16, posttest 25, p = 0.008) evaluation. Increased teamwork and team performance were also noted between scenarios on videotape analysis with significant improvement for adherence to best practice (p = 0.01) and maintenance of positive rapport among team members (p = 0.02). Significant improvement in the setup of the laparoscopic procedure was observed (p = 0.01). Favorable face and content validity was noted for both scenarios. Teamwork, intraoperative communication and laparoscopic skills of urology residents improved during the high fidelity simulation course. Face and content validity of the individual sessions was favorable. In this study high fidelity simulation was effective for assessing and teaching Accreditation Council for Graduate Medical Education core competencies related to intraoperative communication, teamwork and laparoscopic skills.

Pediatric Medication Safety

Children are at risk from adverse medication events. National attention has been focused on medication errors resulting from medication formulation issues to medication administration issues. There is a compelling need to improve strategies that will result in reduced risk as well as reduced harm to children from medication mishaps. Opportunity exists to enhance the efforts of national medication safety groups by identifying teams at every level of care that might best apply research findings to pediatric medication safety processes. This review describes the evidence basis of pediatric medication safety strategies and the national teams that substantially influence the application of these strategies at facility, unit, and community levels, and it asserts that medication safety strategies matter most at the level of the child.

Fault/no fault: bearing the brunt of medical mishaps

“I'd rather not talk about it, even though in the end no fault was found. For 7 years it went on, months sitting in court listening to what a terrible person you are, no one recovers from that. It is on your mind every day, every minute. It changed the whole way I practised. The empathy I had,

The trouble with safety in the National Health Service: a personal view

Public interest in NHS safety has been fired by cataclysmic reports of thousands of patients being killed through medical errors. These terrifying but unreliable figures almost certainly overstate the size of the problem, but the matter is complicated since there are presently no reliable data and there is no common definition of what an avoidable medical mishap is. So a very serious matter is somewhat clouded by confusion. Focusing on death and severe harm through unambiguous human error (a good place to start), the most obvious way to reduce such events is to educate frontline clinical staff about the science of safety – how this has been developed in other fields of human endeavour and how it translates to healthcare. This will take time – a professional generation, probably, as the young are more amenable to new practices than the old. There are other obstacles, including disincentives to report mishaps and a present lack of professional ownership of the safety initiative. But as awareness grows the pace of change will accelerate and better data will give a clearer picture of what is going on.

Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology

Diagnostic errors are poorly understood despite being a frequent cause of medical errors. Recent efforts have aimed to advance the "basic science" of diagnostic error prevention by tracing errors to their most basic origins. Although a refined theory of diagnostic error prevention will take years to formulate, we focus on communication breakdown, a major contributor to diagnostic errors and an increasingly recognized preventable factor in medical mishaps. We describe a comprehensive framework that integrates the potential sources of communication breakdowns within the diagnostic process and identifies vulnerable steps in the diagnostic process where various types of communication breakdowns can precipitate error. We then discuss potential information technology-based interventions that may have efficacy in preventing one or more forms of these breakdowns. These possible intervention strategies include using new technologies to enhance communication between health providers and health systems, improve patient involvement, and facilitate management of information in the medical record.

Time of Day Is Associated With Postoperative Morbidity

To examine the association between surgical start time and morbidity and mortality for nonemergent procedures. Patients require medical services 24 hours a day. Several studies have demonstrated a difference in outcomes over the course of the day for anesthetic adverse events, death in the ICU, and dialysis care. The relationship between operation start time and patient outcomes is yet undefined. We performed a retrospective cohort study of 144,740 nonemergent general and vascular surgical procedures performed within the VA Medical System 2000-2004 and entered into the National Surgical Quality Improvement Program Database. Operation start time was the independent variable of interest. Logistic regression was used to adjust for patient and procedural characteristics and to determine the association between start time and, in 2 independent models, mortality and morbidity. Unadjusted later start time was significantly associated with higher surgical morbidity and mortality. After adjustment for patient and procedure characteristics, mortality was not significantly associated with start time. However, after appropriate adjustment, operations starting between 4 pm and 6 pm were associated with an elevated risk of morbidity (OR = 1.25, P < or = 0.005) over those starting between 7 am and 4 pm as were operations starting between 6 pm and 11 pm (OR = 1.60, P < or = 0.005). When considering a nonemergent procedure, surgeons must bear in mind that cases that start after routine "business" hours within the VA System may face an elevated risk of complications that warrants further evaluation.

Oxygenation Failure During Cardiopulmonary Bypass Prompts New Safety Algorithm and Training Initiative

Developing new strategies to improve patient safety and risk reduction is fundamental to hospital and patient success. Currently, there is a tendency in hospital safety management to focus solely on human error rather than organizational and educational causes that contribute to medical accidents. Although health care providers are the primary safety systems in medical facilities, there must be a more global, perhaps automated, approach using modern technology to prevent or reduce medical mishaps. Herein, we present an oxygenation failure with root cause analysis that prompted a new oxygenation safety algorithm and multi-service training initiative.

Karlene M. Kerfoot, PhD, RN, CNAA, FAAN

Karlene M. Kerfoot, PhD, RN, CNAA, FAAN

Independent federal safety board needed to prevent adverse events

With harsh statistics suggesting adverse events occur in as many as 30% of medical treatments and that as many as 24 000 Canadians die annually due to medical mishaps, a Health Canada-commissioned report contends the health care system must implement a new safety-conscious regime that's far more

The spinal surgeon, the medical mishap, the warning and Afshar

The patient suffering an injury and suing the doctor must establish a causal connection between the operation and the injury. If the doctor was not negligent in carrying out the operation, the patient can still succeed if the doctor did not inform and warn him of the predictable risks, however slight those risks might be, if they would or might have influenced the decision of the patient to consent or not.

Residents?? Responses to Medical Error: Coping, Learning, and Change

To explore the significant emotional challenges facing resident physicians in the setting of medical mishaps, as well as their approaches to coping with these difficult experiences. Twenty-six resident physicians were randomly selected from a single teaching hospital and participated in in-depth qualitative interviews. Transcripts were analyzed iteratively and themes identified. Residents expressed intense emotional responses to error events. Poor patient outcomes and greater perceived personal responsibility were associated with more intense reactions and greater personal anguish. For the great majority of residents, their ability to cope with these events was dependent on a combination of reassurance and opportunities for learning. Interactions with medical colleagues and supervisory physicians were critical to this coping process. Medical mishaps have a profound impact on resident physicians by eliciting intense emotional responses. It is critical that resident training programs recognize the personal and professional significance of these experiences for young physicians. Moreover, resident education must support the development of constructive coping skills by facilitating candid discussion and learning subsequent to these events.

The Pharmacist-Physician Relationship in the Detection of Ambulatory Medication Errors

Expenditures on outpatient prescription drugs have increased enormously in the last decade. Despite this growth in expenditures, prescription medication safety in the ambulatory setting is lacking. Prior research in outpatient care has centered around the physician-patient encounter. What remains unexamined in the ambulatory care literature is the pharmacist's role as interceptor, detector, and reporter of medication errors to the physician. Data about the role, responsibilities, and expectations to inform physicians about this subject were collected from pharmacist (N = 30) and patient (N = 31) focus groups conducted between July 2002 and July 2003. Pharmacists in outpatient practices and patients were randomly selected from the state licensure database and the Jackson Metropolitan phonebook, respectively. Grounded theory provided the perspective on which data were interpreted. Data patterns were linked using key words and phrases for theme analysis. Arbitration between coders resulted in an inter-rater reliability of 0.85. : Three complementary patterns were identified from the data: 1) patients likely see multiple physicians and only one pharmacist; 2) patients are more likely to report medication errors to the pharmacist than to the physician; and 3) pharmacists are the final interceptors, detecting medication errors before they reach patients. Ambulatory pharmacists are in a privileged position to gather data regarding adverse responses to prescribed medication or incidents of medication mishaps. The failure of pharmacists to report information back to physicians is a missed opportunity to improve patient safety.

Communication in Emergency Medicine: Implications for Patient Safety1

Emergency medicine is largely a communicative activity, and medical mishaps that occur in this context are too often the result of vulnerable communication processes. In this year-long qualitative study of two academic emergency departments, an interdisciplinary research team identified four such processes: triage, testing and evaluation, handoffs, and admitting. In each case, we found that narrative rationality (the patient's story) was consistently subjugated to technical rationality (actionable lists). Process changes are proposed to encourage caregivers to either reconsider their course of action or request additional contextual information. A heightened awareness of the bias for technical over narrative rationality and a better recognition of uncertainty in emergency medicine communication are important first steps toward anticipating potential failures and ensuring patient safety.

Voluntary System to Collect Medical-Error Data

Back to table of contents Previous article Next article Government NewsFull AccessVoluntary System to Collect Medical-Error DataRich DalyRich DalySearch for more papers by this authorPublished Online:2 Sep 2005https://doi.org/10.1176/pn.40.17.00400011The number of patient injuries and deaths resulting from medical errors may drop with the implementation of a new law, supported by APA, that creates a national database to accept voluntary medical error reports and identify trends.The law, the Patient Safety and Quality Improvement Act of 2005, authorizes the creation of a network of patient safety databases, or patient safety organizations (PSOs), to accept voluntary, nonidentifiable patient safety reports from state-authorized health care providers or organizations. The Department of Health and Human Services (HHS) will use the reports to analyze trends in medical errors for the public. The law tightly restricts release of the data to other entities.A key feature of the law that helped garner the support of APA and other medical and advocacy groups was the inclusion of language shielding data from use in medical malpractice litigation.“The concern that APA had—as well as the rest of the medical specialties—is anything that goes to improving patient safety is a great idea, but there were legitimate concerns about whether or not open access to and full disclosure of patient-specific and physician-specific information would simply increase liability,” said Nicholas Meyers, director of APA's Department of Government Relations.The law, signed by President George W. Bush on July 29 and effective immediately, allows individual health care providers, hospitals, and other health care organizations to report errors to the PSOs, which will analyze the errors, look for weaknesses in the system that contribute to errors, and recommend ways to prevent future mistakes.The law does not shield medical error information submitted under the law from use in malpractice litigation when it is obtained from other sources. The release of database information could occur in limited situations, including some criminal cases or when all of the parties involved allow it.The database's use of voluntary reports and confidentiality safeguards is intended to give physicians and other health professionals the confidence to report medical mishaps thoroughly, Meyers said, which will improve patient care, rather than risking additional legal liability.The effort to gain enactment of the law was led by the AMA. The AMA has long maintained that hospitals and doctors are reluctant to report errors because they fear lawsuits.Patient safety efforts gained momentum when the Institute of Medicine reported in 1999 that as many as 98,000 Americans die from medical errors in U.S. hospitals each year (Psychiatric News, April 21, 2000).Al Herzog, M.D., chair of APA's Committee on Patient Safety and the Psychiatric News Editorial Advisory Board, said the law will help improve patient safety while allowing physicians to report errors on a voluntary, nonpunitive basis. Herzog said the reporting of adverse events and“ near misses” allows physicians to learn from others' mistakes.The law, however, could have gone further, Herzog said. “My one regret is it does not override the state-reporting mandates, many of which are quite punitive at times and not done in this positive way,” he said.Thus, state laws that mandate separate medical error reports to state health agencies or the availability of that information to malpractice plaintiffs take precedence.The law bars employers from penalizing or firing health care professionals who report medical errors to the databases in good faith.These are among the law's other provisions:Prohibits an accrediting body from taking any accrediting action against a provider based on the provider's good faith participation in collecting, developing, reporting, or maintaining patient safety data.Protects a provider's communications with any PSO.Establishes a $10,000 civil penalty for each identifiable illegal disclosure.Requires a HHS report within two and a half years of the database's becoming operational that identifies effective strategies for reducing medical errors and increasing patient safety.Establishes PSO certification procedures.Requires HHS to maintain a list of certified PSOs.Requires HHS to develop methodologies for the collection of patient safety data and provide technical assistance to PSOs.Require HHS to develop voluntary national standards that promote the comparability of medical information technology systems.The Congressional Budget Office estimates that implementation of the databases will cost $5 million in 2006 and $58 million between 2006 and 2010.The text of the Patient Safety and Quality Improvement Act of 2005 (PL 109-41) will be posted soon at<www.access.gpo.gov/nara/publaw/109publ.html>. The report of APA's Committee on Patient Safety, “Patient Safety and Psychiatry,” is posted at<www.psych.org/edu/other_res/lib_archives/archives/tfr/tfr200301.pdf>.▪ ISSUES NewArchived

Preventing communication errors in telephone medicine

Errors in telephone communication can result in outcomes ranging from inconvenience and anxiety to serious compromises in patient safety. Although 25% of interactions between physicians and patients take place on the telephone, little has been written about telephone communication and medical mishaps. Similarly, training in telephone medicine skills is limited; only 6% of residency programs teach any aspect of telephone medicine. Increasing familiarity with common telephone challenges with patients may help physicians decrease the likelihood of negative outcomes. We use case vignettes to highlight communication errors in common telephone scenarios. These scenarios include giving sensitive test results, requests for narcotics, managing ill patients who are not sick enough for the emergency room, dealing with late-night calls, communicating with unintelligible patients, and handling calls from family members. We provide management strategies to minimize the occurrence of these errors.

Attitudes About Patient Safety: A Survey of Physicians-in-Training

Little is known about the attitudes of physicians-in-training on patient safety, although success in error reduction strategies requires their support. We surveyed house staff and fourth-year medical students from 1 academic institution about their perceptions of adverse patient events. Three hundred twenty-one trainees (41%) completed the survey. Most believe adverse events are preventable (61%) and think improved teamwork (88%), better procedural training (74%), and improved sign-out (70%) would reduce medical mishaps. Forty-seven percent of trainees agree computerized order entry and restricted work hours would prevent adverse events. Although 60% feel malpractice fears inhibit discussion, 80% of trainees agreed physicians must disclose adverse events to patients and grow more comfortable with disclosure as training progresses (P for trend<.01). In conclusion, trainees believe adverse events are preventable and are poised to respond to many components of the patient safety movement.

A demographic profile of new traumatic spinal cord injuries: Change and stability over 30 years

Jackson AB, Dijkers M, DeVivo M, Poczatek RB. A demographic profile of new traumatic spinal cord injuries: change and stability over 30 years. Arch Phys Med Rehabil 2004; 85:1740-8. Objective To evaluate epidemiologic trends in new spinal cord injuries (SCIs) in the United States over 3 decades. Design Consecutive case series. Setting Model Spinal Cord Injury Systems (MSCIS) facilities. Participants Persons (N=30,532) admitted to MSCIS facilities within 365 days of injury between 1973 and 2003, and enrolled in the National Spinal Cord Injury Database. Interventions Not applicable. Main outcome measures Data were collected at MSCIS admission and rehabilitation discharge. Variables included age, gender, race and ethnic group, year of injury, and level and extent of injury. Specific etiologies were grouped as motor vehicle collisions (MVCs), violence, falls, sports, and other. Demographic and injury severity trends were analyzed by year of injury groupings according to decades (1973–1979, 1980–1989, 1990–1999, 2000–2003.) Chi-square tests assessed statistical significance. One-way analysis of variance compared mean ages. Results The male/female ratio remained fairly stable at 4:1, but the percentage of women increased slightly over time, especially from MVC etiologies ( P<.001). Over time, the mean age at injury increased significantly ( P<.001); it was 37.7±17.5 years in 2000–2003. The majority of cases were white (66.1%). Tetraplegia (54.1%) and complete injuries (55.6%) occurred more than paraplegia and incomplete injuries, respectively. MVCs (45.6%) remained the most common etiology; falls (19.6%) held the second position over violence (17.8%), except for the 1990–1999 period when the positions were reversed. Significantly increasing percentages of new injuries were seen for SCI due to automobile, motorcycle, bicycle, and all-terrain vehicle crashes, blunt object attacks, snow skiing, and medical and surgical mishaps. Conclusions Many previously seen SCI demographic trends continued into the 2000 decade.