Who takes the blame for medical errors?

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Surgical errors can be minimized by the use of a universal protocol.
Surgical errors can be minimized by the use of a universal protocol.

At a glance

  • The estimated total costs of medical errors approach $29 billion per year.
  • Clinicians should verify the appropriateness of their patients' current medications at each encounter.
  • Underreporting has been cited as a consequence of our fault-based system of compensating medical injuries.
  • The malpractice system represents just one mechanism for overseeing medical quality.

According to a 2000 report from the Institute of Medicine (IOM), as many as 98,000 hospitalized patients die each year as a result of medical errors.1 Additionally, medical errors cause physical and psychological suffering. In economic terms, the estimated total costs of medical errors approach $29 billion per year. Further, medical errors erode public confidence in the health-care system and decrease worker productivity and school attendance.

An error may be defined as "the failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim."1 In contrast, an adverse event is defined as "an injury resulting from a medical intervention."1 Some errors result in injury, but not all errors cause adverse events. Those that do not are referred to as near misses. Conversely, some (but not all) injuries sustained during medical interventions (adverse events) result from medical errors. Because the practice of medicine is a hazardous activity, sometimes patients are injured despite the delivery of appropriate medical care.

Why is the error rate so high?

A seminal article in The Journal of the American Medical Association2 cites a study of errors in an intensive care unit that revealed an average of 1.7 errors per day per patient, of which 29% had the potential for serious or fatal injury. The patients in the study were the recipients of 178 "activities" per day, so hospital personnel were functioning at 99% efficiency. While that sounds positive, the author points out, "[A] 1% failure rate is substantially higher than is tolerated in...[other] hazardous fields such as aviation and nuclear power...[E]ven 99.9% may not be good enough."2

The author suggests that medicine could learn a great deal from the aviation industry, which has posted an exemplary safety record since the 1970s. Specifically, medicine should accept that errors are inevitable and design systems (employing automation and redundancy) to absorb those errors, employ checklists and standardization of procedures, and endeavor to institutionalize safety.

Types of medical errors

There are a number of different types of medical errors, but this article will focus on medication and surgical errors.

Medication errors

Case 1: Michelle was diagnosed with congenital heart disease at age 2 months. The infant required digitalization, and Dr. S, the cardiologist, ordered "Elixir pediatric lanoxin 2.5 cc (0.125 mg) q6h 3 then once daily." Because the third of the three digitalization doses was not administered in a timely fashion by the nursing staff, Michelle's mother requested and was granted permission by Dr. S to administer the daily maintenance dose of 2.5 cc in the future. The infant was discharged home to await the scheduling of cardiac surgery but required readmission before the operation could be performed.

Upon readmission, Dr. S decided Michelle needed an increase in the daily maintenance dose of lanoxin. Michelle's mother was instructed to increase the lanoxin to 3 cc for that day only. On the order sheet, Dr. S noted "Give 3.0 cc lanoxin today for one dose only."

A member of the nursing staff administered 3 cc lanoxin in its injectable form instead of the elixir form as Dr. S intended (the concentration of the injection was 0.25 mg/cc vs. 0.05 mg/cc for the elixir). The infant died approximately 75 minutes after this injection. It was readily conceded by all parties that the lanoxin injection was a lethal overdose and the cause of the infant's death.3

This case involved errors at multiple stages of the medication process, including the ordering stage (failure to specify route and failure to mention that the dose had already been administered) and the administration stage (failure to clarify an ambiguous order before administration). Not surprisingly, a malpractice suit ensued, and the physician and nurse were found to have acted negligently.

The IOM estimates that a hospital patient is subject to at least one medication error per day and that approximately 25% of all adverse drug events (ADEs) are preventable. There are an estimated 1.5 million preventable ADEs per year in the United States, resulting in approximately 7,000 deaths.4

In a 2004 report, the IOM found that "because the number of outpatient encounters far exceeds the number of inpatient admissions, the consequences of medical errors in the [outpatient] setting may dwarf those in hospitals."5 The report went on to suggest that errors of omission (e.g., failing to prescribe an angiotensin-converting enzyme inhibitor for a diabetic with proteinuria) might pose a greater threat to health than errors of commission.

Surgical errors

Case 2: Mr. K, a 51-year-old diabetic with severe peripheral vascular disease, was hospitalized for amputation of a gangrenous right leg. The admitting clerk mistakenly entered into the computer system that the patient was scheduled for a below-the-knee amputation of the left leg. Mr. K's surgeon read the wrong procedure off one of the printed schedules, prepped the wrong leg, and amputated it. The gangrenous right leg was amputated a few weeks later. Mr. K received a settlement of $900,000 from the hospital and $250,000 from the surgeon who was fined, suspended, and placed on probation.6

Mr. K's case offers a particular type of surgical error (wrong-site/wrong-patient surgery). Other surgical errors include cases of retained sponges and instruments and mistakes related to volume-outcome relationships. For an illustration of the latter, consider the next case.

Case 3: Ms. J underwent a CT scan to determine the cause of her headaches and was referred to a local neurosurgeon, Dr. M. The neurosurgeon diagnosed an enlarging aneurysm at the rear of Ms. J's brain and recommended surgery. Unfortunately, Ms. J, who had no prior neurologic impairments, was rendered an incomplete quadriplegic postoperatively.

In the ensuing malpractice trial, Ms. J argued that her adverse outcome resulted from the surgeon's relative inexperience and that Dr. M had been negligent in eliciting informed consent. She introduced evidence that Dr. M had overstated his experience in performing the particular type of aneurysm surgery she required. Ms. J testified that Dr. M had told her he had performed the surgery "several" times. When asked what he meant by several, Dr. M replied "dozens" and "lots of times." In fact, he had operated on basilar bifurcation aneurysms only twice and had never operated on a basilar bifurcation aneurysm as large as Ms. J's. The jury found in favor of Ms. J. The decision was upheld by the state Supreme Court, which wrote, "The plaintiff introduced ample evidence that had a reasonable person in her position been aware of the defendant's relative lack of experience in performing basilar bifurcation aneurysm surgery, that person would not have undergone surgery with him."7

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