Medical Errors and Adverse Events: Managing the Aftermath

Prospective collection of adverse events involves researchers or clinicians at the clinical interface identifying events as they occur.

Medical errors II, the aftermath: Mea culpa!

This may entail any combination of chart review, electronic searches, interviewing patients and staff, direct observation on the ward and clinical examination of patients. Thus, it can be difficult to judge preventability and may not be optimal for assessing the impacts of interventions to reduce adverse events or system factors responsible for particular events.

Existing electronic data e. However, these data usually collected for other purposes are dependent on the accuracy of the diagnostic coding system and limitations of the coding dictionary and have been found to have relatively poor sensitivity and specificity for adverse event identification. Preliminary work adapted some of these for use with NHS admissions data. The study found that admissions with these codes had higher mortality, length of stay and readmission rates.

There was, however, substantial variability between trusts and it is not clear whether this was due to variations in secondary diagnosis coding or quality of care. A major barrier to progress in the field of patient safety appears to be the lack of reliable information on adverse events. More importantly though is the need to move from unsystematic methods such as voluntary reporting to coordinated systematic measurement. This could involve a combination of several methods including national audits, screening programmes e.

The lack of systematic adverse event measurement and reporting is likely to have contributed to the absence of clear evidence of an overall reduction in adverse events. Twenty years on from the first retrospective chart review studies, patient safety and quality are an accepted part of healthcare delivery but there remains a lack of consensus on how to collect and measure adverse events. This has meant progress is difficult to quantify.

The system, therefore, has a limited ability to learn from its mistakes. In order to achieve and monitor healthcare sector improvements in patient safety we must plan for, and implement, inter national, standardized and systematic measurement of adverse events alongside a sustained focus on a culture of safety in all areas of healthcare delivery. Only once this is occurring can we effect whole system change and observe overall impacts on patient care.

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Close mobile search navigation Article navigation. A systems approach and a safety culture that learns from adverse events. Reason to collect adverse event data. Lack of consistent measurement of adverse events hampers progress. Adverse events in healthcare: View large Download slide. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: Last accessed 13 July Incidence of adverse events and negligence in hospitalized patients: Incidence and types of adverse events and negligent care in Utah and Colorado.

Adverse events in British hospitals: The Canadian Adverse Events Study: Ministry of Health and Consumer Affairs, The incidence of adverse events in Swedish hospitals: Adverse events and potentially preventable deaths in Dutch hospitals: Extent, nature and consequences of adverse events: Detection of adverse events in a Scottish hospital using a consensus-based methodology.

Medical errors II, the aftermath: Mea culpa!

The incidence and nature of in-hospital adverse events: Culture and behaviour in the English National Health Service: Medical error, incident investigation and the second victim: Practitioners often fear that such disclosure may result in litigation, loss of trust by the patient and family, or the tarnishing of their professional reputation. Full disclosure is a process, not an event. In most cases, the responsible care provider leads the disclosure and delivers the apology if an apology is indicated.

The result can be an impersonal demeanor which leads patients to view physicians as uncaring. Disclosure relieves the anxiety of not knowing and reaffirms an open, honest physician-patient-family relationship. Such transparency has been demonstrated to decrease litigation as well as the average settlement amount for claims that are filed. Patients and families also want an apology. However, this omission is perceived as cold, heartless, and impersonal by patients and families. They correctly feel angry and distanced, which is toxic to the physician-patient-family relationship and actually may increase the likelihood of litigation.

In the United States, some states have enacted statutes that prevent an apology from being used against a physician in a law suit. Patients and families have their own fears: On account of the power dynamics between physicians and patients, questioning the expertise or skill of an authority figure is particularly fraught with apprehensions for the least empowered.

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• DETECTION OF MEDICAL ERRORS AND ADVERSE EVENTS?

Given the nature of the emotions provoked by medical error, feelings of isolation can be particularly harmful. The sense that somebody could empathize and know what I was feeling. In many cases, more than one clinician is involved and may feel responsible.

Resultant feelings of guilt, anxiety, ineptitude or lowered confidence can be devastating, leading to inappropriate behaviors such as lashing out at patients, families, and colleagues and to unhealthy behaviors such as substance abuse. Distress escalates in the face of a malpractice suit. Clinicians who feel guilty after a medical error may have parallel feelings of fear-fear for their reputation, their job, their license, and their own future as well as that of their patient.

Medical errors are too often a taboo subject. They haunt the conscience of those involved and medical personnel naturally find them difficult to discuss. Disclosing one's own experience of mistakes can reduce the colleague's sense of isolation. It is helpful to ask about and acknowledge the emotional impact of the mistake and ask how the colleague is coping. Strangely, there is no place for mistakes in modern medicine.

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Society has entrusted physicians with the burden of understanding and dealing with illness. Patients, who have an understandable need to consider their doctors infallible, have colluded with doctors to deny the existence of error. Many errors are built into existing routines and devices, setting up the unwitting physician and patient for disaster.

Also, although patients are the first and obvious victims of medical mistakes, doctors are wounded by the same errors: The ideal response is to think of error as a systems failure rather than an individual failing.

Medical Errors and Adverse Events - Managing the Aftermath: Managing the Aftermath (Hardcover)

The tactics with which this can be done are: The building of a safe health-care system rests on the belief that safety is everyone's business. The top management in the case of a hospital or the individual practitioner needs to accept setbacks and anticipate errors, review. This can occur if safety related information is easily accessible to all levels of the staff, all clinic and hospital staff meet regularly on safety issues, messengers are rewarded, and there is a just and reporting culture, with qualified indemnity and confidentiality and disciplinary systems agree between acceptable and unacceptable behaviors.

The existence of protocols written by those doing the job, which are intelligible and workable, coupled with training in recognition and recovery of errors, and most importantly, feedback on recurrent error patterns help mitigate errors. When mishaps occur, the decency to acknowledge responsibility, apologize, and convince patients and victims that lessons learned will reduce chance of recurrence is of essence. What can certainly be done, however, is to minimize the disastrous consequences by regular clinical audits, and a shift of emphasis from blame to learning, from individuals to system and from fault finding to fact finding.

They are asking us to promise something reasonable, but more than we have ever promised before: We owe them nothing less, and that debt is now due. National Center for Biotechnology Information , U. Journal List Indian J Psychiatry v. Swaminath Department of Psychiatry, Dr.

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Author information Copyright and License information Disclaimer. G Swaminath, Department of Psychiatry, Dr. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3. The top management in the case of a hospital or the individual practitioner needs to accept setbacks and anticipate errors, review past events and implement changes and concentrate on fixing the system rather than the individual in case of an error. Footnotes Source of Support: Nil Conflict of Interest: Getting it right when things go wrong.

Patient safety and quality improvement: Medical errors and adverse events. Five years after To Err Is Human: