The subject of medical errors is not a new one. However, it did not come to widespread attention in the United States until the 1990s, when government-sponsored research about the problem was undertaken by two physicians, Lucian Leape and David Bates. In 1999, a report compiled by the Committee on Quality of Health Care in America and published by the Institute of Medicine (IOM) made headlines with its findings. As a result of the IOM report, President Clinton asked the Quality Interagency Coordination Task Force (QuIC) to analyze the problem of medical errors and patient safety, and make recommendations for improvement. The Report to the President on Medical Errors was published in February 2000.
It is important to understand the terms used by the government and health-care professionals in describing medical errors in order to distinguish between injury or death resulting from mistakes made by people on the one hand, and unfortunate results of treatment on the other. Some allergic reactions to medications or failures to respond to cancer treatment, for example, result from physical differences among patients or the known side effects of certain treatments, and not from prescribing the wrong drug or therapy for the patient's condition. This type of negative outcome is called an adverse event in official documents. Adverse events can be defined as undesirable and unintentional, though not necessarily unexpected, results of medical treatment. An example of an adverse event is discomfort in an artificial joint that continues after the expected recovery period, or a chronic headache following a spinal tap.
A medical error, on the other hand, is an adverse event that could be prevented given the current state of medical knowledge. The QuIC task force expanded the IOM's working definition of a medical error to cover as many types of errors as possible. Their definition of a medical error is as follows: "The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems." A useful, brief definition of a medical error is that it is a preventable adverse event.
The statistics contained in the IOM report were startling. The authors of the report stated that between 45,000 and 98,000 Americans die each year as the result of medical errors. If the lower figure is used as an estimate, deaths in hospitals resulting from medical errors are the eighth leading cause of mortality in the United States, surpassing deaths attributable to motor vehicle accidents (43,458), breast cancer (42,297), and AIDS (16,516). Moreover, these figures refer only to hospitalized patients; they do not include people treated in outpatient clinics, ambulatory surgery centers , doctors' or dentists' offices, college or military health services, or nursing homes . Medical errors certainly occur outside hospitals; in 1999, the Massachusetts State Board of Registration in Pharmacy estimated that 2.4 million prescriptions are filled incorrectly each year in that state—which is only one of 50 states.
In terms of health-care costs, the IOM report estimated that medical errors cost the United States about $37.6 billion each year; about half this sum pays for direct health care.
The United States is not unique in having a high rate of medical errors. The United Kingdom, Australia, and Sweden are presently undertaking studies of their respective health care systems. British experts estimate that 40,000 patients die each year in the United Kingdom as the result of medical errors. Australia has been testing a new system for reporting errors since 1995.
There is no single universally accepted method of classifying medical errors in order to describe them more fully. The 2000 QuIC report lists five different classification schemes that have been used:
The importance of these different ways to classify medical errors is their indication that different types of errors require different approaches to prevention and problem solving. For example, medication errors are often related to such communication problems as misspelled words or illegible handwriting, whereas surgical errors are often related to unclear or misinterpreted diagnostic images.
The causes of medical errors are complex and not yet completely understood. Some causes that have been identified include the following:
One subject that has been emphasized in recent reports on medical errors is the need to move away from a search for individual culprits to blame for medical errors. This judgmental approach has sometimes been called the "name, shame, and blame game." It is characterized by the belief that medical errors result from inadequate training or from a few "bad apples" in the system. It is then assumed that medical errors can be reduced or eliminated by identifying the individuals, and firing or disciplining them. The major drawback of this judgmental attitude is that it makes health care workers hesitate to report errors for fear of losing their own jobs or fear of some other form of reprisal. As a result of underreporting, hospital managers and others concerned with patient safety often do not have an accurate picture of the frequency of occurrence of some types of medical errors.
Both the IOM report and the QuIC report urge the adoption of a model borrowed from industry that incorporates systems analysis. This model emphasizes making an entire system safer rather than punishing individuals; it assumes that most errors result from problems with procedures and work processes rather than bad or incompetent people; and it analyzes all parts of the system in order to improve them. The industrial model is sometimes referred to as the continuous quality improvement model (CQI). Hospitals that are implementing error-reduction programs based on the CQI model have found that a non-punitive procedure for reporting medical errors has improved morale among the staff as well as significantly reduced the number of medical errors. At Columbia-Presbyterian Hospital, for example, patients as well as staff can report medical errors via the Internet, a telephone hotline, or paper forms.
Current proposals for reducing the rate of medical errors in the American health care system include the following:
Patients are an important resource in lowering the rate of medical errors. The QuIC task force has put together some fact sheets to help patients improve the safety of their health care. One of these fact sheets, entitled "Five Steps to Safer Health Care," gives the following tips:
This fact sheet, as well as a longer and more detailed patient fact sheet on medical errors, is available for free download from the Agency for Health Research and Quality (AHRQ) Website or by telephone order from the AHRQ Publications Clearinghouse at (800) 358-9295.
Committee on Quality of Health Care in America, Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 2000.
Aiken, Linda H., et al. "Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction." Journal of the American Medical Association 288 (October 23-30, 2002): 1987–1993.
Cottrill, Ken. "Mistaken Identity: Barcoding Recommended to Combat Medical Errors." Traffic World (July 2, 2001).
Dougherty, Matthew. "Preventing Errors: New Initiative Aims to Catch Mistakes before They Happen." In Vivo: News from Columbia Health Sciences 1 (February 11, 2002).
Dovey, S. M., R. L. Phillips, L. A. Green, and G. E. Fryer. "Types of Medical Errors Commonly Reported by Family Physicians." American Family Physician 67 (February 15, 2003): 697.
Friedman, Richard A. "Do Spelling and Penmanship Count? In Medicine, You Bet." New York Times, March 11, 2003.
Gallagher, T. H., et al. "Patients' and Physicians' Attitudes Regarding the Disclosure of Medical Errors." Journal of the American Medical Association 289 (February 26, 2003): 1001–1007.
Grady, Denise, and Lawrence K. Altman. "Suit Says Transplant Error Was Cause in Baby's Death in August." New York Times, March 12, 2003.
Hsia, David C. "Medicare Quality Improvement: Bad Apples or Bad Systems?" Journal of the American Medical Association 289 (January 15, 2003): 354–356.
Nordenberg, Tamar. "Make No Mistake: Medical Errors Can Be Deadly Serious." FDA Consumer Magazine (September-October 2000).
Pyzdek, Thomas. "Motorola's Six Sigma Program." Quality Digest (December, 1997).
Agency for Healthcare Research and Quality (AHRQ). 2101 East Jefferson St., Suite 501, Rockville, MD 20852. (301) 594-1364. http://www.ahcpr.gov .
Institute of Medicine (IOM). The National Academies. 500 Fifth Street, NW, Washington, DC 20001. http://www.iom.edu .
United States Food and Drug Administration (FDA). 5600 Fishers Lane, Rockville, MD 20857-0001. (888) 463-6332. http://www.fda.gov .
Agency for Healthcare Research and Quality (AHRQ) Fact Sheet. Medical Errors: The Scope of the Problem. Publication No. AHRQ 00-PO37.
Agency for Healthcare Research and Quality (AHRQ) Patient Fact Sheet. 20 Tips to Help Prevent Medical Errors. Publication No. AHRQ 00-PO38.
Burton, Susan. "The Biggest Mistake of Their Lives." New York Times, March 16, 2003. http://www.nytimes.com/2003/03/16/magazine/16MISTAKE.html .
Quality Interagency Coordination Task Force (QuIC)) Patient Fact Sheet. Five Steps to Safer Health Care, January 2001 [cited March 17, 2003]. http://www.ahrq.gov/consumer/5steps.htm .
Report of the Quality Interagency Coordination Task Force (QuIC) to the President. Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact, 2000.
Rebecca Frey, PhD