Medical Errors: Lessons Learned from Industry

Advances in Skin & Wound Care, Jul/Aug 2004 by McGuckin, Maryanne

Each day, 100 patients hospitalized in the United States die from medical errors and adverse events related to their care, not from the reason they were admitted to the hospital.

Understandably, health care consumers are fearful of medical errors. A national poll conducted by the National Patient Safety Foundation1 found that 42% of respondents were either personally affected by a medical error or had a friend or relative who was. Thirty-five percent indicated that the error had a permanent adverse effect on the person's health.1 The costs associated with these errors in lost income, disability, and increased health care costs are as much as $9 29 billion annually.2

According to the Institute of Medicine's (IOM) 1999 report, To Err is Human: Building a Safer Health System,3 medical errors result from system problems rather than from poor performance by individual providers. The IOM defines a medical error as "the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim, with the error occurring either in the planning stage or the execution stage."3 In wound care, an example would be ordering compression without first assessing the adequacy of the patient's arterial perfusion via the ankle-brachial index.

An adverse event is defined by IOM as "an injury caused by medical management rather than by the underlying disease or condition of the patient."3 Adverse events resulting in medical errors are considered preventable adverse events or sentinel events. An example is illegibly handwritten orders or lack of communication between primary physician and wound care provider that results in patient injury.

Impact of the IOM Report

November 2004 marks the fifth anniversary of the release of the TOM report. One directive in that report is to reduce errors by one-half over this period, utilizing a 4-tier approach:

1. Establish a national focus to create leadership, research, tools, and protocols to enhance the knowledge about safety.

2. Identify and learn from medical errors through both mandatory and voluntary reporting systems.

3. Raise standards and expertise for improvements in safety through the actions of oversight organizations, group insurance purchasers, and professional groups.

4. Implement safe practices at the delivery level.

Three months after the release of the IOM report, the federal government organized a Quality Interagency Coordination Task Force (QuIC) to respond to the report with a strategy to reduce medical errors. As a result, 7 national patient safety goals4 were approved by the Joint Commission on Accreditation of Healthcare Organizations and implemented in January 2003. These include fairly simple strategies, such as accuracy of patient identification, effectiveness in communication among caregivers, improvement of safety when using infusion pumps, reduction in health care-acquired infections, and improvement in hand hygiene.

Learning from Industry

These measures are a good first step, and they have provided effective ways to identify errors. We must now take that second step and move in the direction of building a health care system that allows for honest and open disclosure of medical errors to patients and involvement of patients in their health care decisions.

Leape et al5 report that on average, patients in intensive care units experience almost 2 errors per day; 1 out of 5 of these errors is potentially serious or fatal. They point out that applying the same error rates to the airline and banking industries would equate to 2 dangerous landings per day at O'Hare International Airport in Chicago and 32,000 checks deducted from the wrong account per day.

Industry, however, has developed models for avoiding these types of problems. The late John Eisenberg, MD, director of the Agency for Healthcare Research and Quality, noted several examples, such as vehicles that cannot be locked unless the key is on the outside and automatic teller machines that do not dispense money until the bank card has been removed.6

At Toyota Motor Corporation, any employee can stop the assembly line when a serious problem is noted. This concept has been applied recently to health care.7 Toyota has identified 4 key techniques in their program: flow, root-cause analysis, value stream mapping, and kaizen. Table 1 defines these terms and suggest how they can be applied to wound care.

Tom Nolan, one of the leading quality improvement scholars of our time, has said, "There are 3 essential preconditions for improvement in our health care: 1) will, 2) ideas, and 3) execution."8 We must all work together, as a team, to prevent further errors and to realize the strength in acknowledging our weaknesses.

References

1. National Patient Safety Foundation. Public opinion of patient safety issues: research findings; 1997. Available online at http://www.npsf.0rg/download/1997survey.pdf; accessed june II,2004.

2. Parker HC. Preventing medical errors. National Association for Continuing Education, Plantation, FL; 2003.