Medical errors

Institute of Medicine definition-failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim.

The number of potential deaths due to medical errors each year may range as high as 98,000, which is greater than the number that occur from motor vehicle accidents, breast cancer, AIDS, or workplace accidents, respectively.

The Harvard medical practice study conducted a sample of patients are hospitalized in New York State in 1984 and the results were published in 1991: adverse event rate of 3.7 events per hundred admissions, of which 28% were judged to have been caused by negligence; 16% lead to death or permanent disability.

Recent estimate of 400,000, deaths due to medical error, more than 1000 per day (James JT).

Recent studies, suggest adverse in Hospital events are common and preventable nearly 1/4 of the time,  identified in approximately 7% of all admissions.

Preventable adverse events are categorized as serious, life-threatening, or fatal, and have recently been identified in approximately 1% of cases.

Study of conditions across multiple countries, found adverse events occurred in approximately one in 10 admissions and almost half were considered to be preventable.

In most studies, a surgical or other procedure and adverse drug events are the most common.

Reportedly account for a major source of inpatient death, responsible for 100 to 200,000 deaths yearly in the US.

Serious non-fatal medical errors occur 10-20 fold higher rate than fatal errors.

Total annual costs related to medical errors, including health care and disability expenditures as well as lost income and productivity, are estimated at $37 to $50 billion, with preventable adverse events projected to run as high as $17 to $29 billion.

Preventable medical errors are estimated to represent as much as 2% of total health care costs.

A bad outcome does not mean a medical error has occurred.

Are unintended and generally preventable.

Must be distinguished from adverse event, which reflects harm that is the result of the process of healthcare rather than the patient’s underlying disease.

The overlap between medical errors and adverse events is small, as most medical errors are not associated with harm, and most adverse events are not a result of medical errors.

Schoen et al. studying 1527 patients in a survey in 2005 found that active users of health care had reported a 34% rate of having a medical error in the previous two years.

Massachusetts experienced 61,982 medical errors in one year(2013) , which translated into an estimated $617 million in excess health insurance claims.

Hospital mortality significantly higher following end-of – month resident handoff (Denson JL et al).

Concluding that all patients with elevated blood troponin levels have had an acute myocardial infarction: there are many clinical situations in which there are acute or chronic myocardial injury with ischemia not present and these latter injuries are not myocardial infarctions.
Concluding that all patients with a diagnosis of acute coronary syndrome should be placed on supplementary oxygen: if a patient’s oxygen saturation is less than 90% supplemental inspiratory oxygen is appropriate.
An error consists of a patient complaining of a sore throat, with erythema, and an exudate being treated with antibiotics to prevent rheumatic fever: most cases of pharyngitis are viral in nature, including many with exudates on the tonsils or the pharynx.
In the above situation antibiotic therapy is a waste of money and may encourage the growth of antibiotic resistant bacteria.
A throat culture is appropriate in such patients, and if the culture grows streptococcus pyogenes antibiotics are appropriate.
Concluding that patient who has chest pain that is resolved with sublingual nitroglycerin have had an anginal episode secondary to coronary artery disease: many such patients with chest pain not secondary to myocardial ischemia will report resolution of the chest discomfort with sublingual nitroglycerin.
Many patients with erythema and swelling of the skin of the distal lower extremity have cellulitis and should receive antibiotics while the process may be due to chronic venous insufficiency that is not responsive to antibiotics.
Attributing an upper G.I. bleed in an alcoholic cirrhotic as an esophageal variceal bleed is not true, the most common cause of G.I. bleeding in a patient with alcoholic cirrhosis is gastritis.
In recent years there has been a significant decrease in the rates of adverse events in hospitalized patients admitted for acute myocardial infarction, heart failure, pneumonia, major surgical procedures.
Monitoring system to address events during hospitalization:
Adverse drug events
Digoxin, hypoglycemic agents, heparin, low molecular weight heparin, factor Xa inhibitors, warfarin.
 Hospital acquired infections
Central line associated bloodstream infections, postoperative pneumonia, hospital acquired antibiotic associated Clostridium difficile, catheter associated urinary tract infections, hospital acquired methicillin resistant staph aureus, hospital acquired vancomycin resistant enterococcus, ventilator assisted pneumonia.
Adverse events after a procedure
Hip replacement, knee joint replacement, complications associated with central lines, postoperative venous thromboembolic events, postoperative cardiac events, femoral artery puncture or catheter and geographic procedures, contrast nephropathy
General adverse events Include hospital acquired pressure ulcers, and falls.
Since the Harvard Medical Practice Study, there has been effective strategies for preventing specific types of adverse events, such as catheter related to bloodstream infections, common surgery related adverse events.
Protocols with triggers, whereby information in the medical record that was previously shown to be associated with adverse events is identified.
Adverse drug events defined as injuries resulting from drugs that were taken occur, much more often, involuntary incident reporting, with one study, suggesting a measured incidence almost 20 times as high as the incense identified through voluntary reporting.
In a random sample of 2809 admissions, at least one adverse event was identified in 23.6% of patients (Bates DA, 2023).
Among 7978, adverse events, 22.7% were judged to be preventable and 32.3%, had a severity of seriousness that caused harm or prolonged recovery: 06.8% were preventable adverse events and a preventable adverse event with severity, level of serious or higher, was preventable in 1% of cases.
in the above study adverse drug events were the most common adverse events accounting for 39% of all events, followed by surgical or other procedural events at 30.4%, patient care events associated with nursing care, including falls, and pressure ulcers was 15%, and healthcare associated infections 11.9%.

The Agency for Healthcare Research and Quality (AHRQ) study released December 15, 2022: estimated rates for diagnostic error at 5.7%, missed diagnosis related harms at 2%, serious misdiagnosis related harms at  0.3%, which could translate into more than 7 million errors, 2.5 million harms, and 350,000 patients suffering, potentially preventable, permanent, disability, or death.

Recent assessments have found that over the past decade, healthcare associated infections, adverse drug events, and patient care events, including falls  and pressure ulcers have declined:the COVID-19 pandemic may have reversed these trends.


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