Medical Mistakes: How Can They Be Prevented?

We've all heard the horror stories: a patient enters the hospital to have one leg amputated and the other is removed instead. A woman who writes about health care issues dies from a chemotherapy overdose. While we’d like to believe these are just rumors, unfortunately the cases are real. In the opening paragraphs of its groundbreaking patient safety report, To Err Is Human: Building a Safer Health System, the Institute of Medicine contends that every year thousands of hospital patients (estimates range from 44,000-98,000) die as a result of medical errors.

Humans are fallible. Every one of us knows this, yet somehow we expect doctors and nurses to be different – they should be perfect. But, just like the rest of us, they do make mistakes. If we acknowledge this fact we’re more likely to find a way to design systems that reduce the likelihood of future errors.

Jerome Van Ruiswyk, MD, Medical College of Wisconsin Associate Professor of Medicine, practices at Zablocki VA Medical Center. He has considerable experience in the area of patient safety, and is participating in a pilot program to develop materials for teaching patient safety concepts to medical staff, residents, students and volunteers.

“The VA has been a leader in patient safety,” says Dr. Van Ruiswyk, citing the Department of Veterans Affairs' National Center for Patient Safety (NCPS) as one example of the VA’s commitment. As a result of NCPS, VA system-wide problems are now being addressed and health care workers are showing an increased willingness to disclose events that have traditionally been underreported. The NCPS has been recognized by the Innovations in American Government Award Program for its development of an original and effective federal program to prevent health care errors.

Dr. Van Ruiswyk emphasizes that medical errors are not the same as malpractice. The Institute of Medicine defines error as the “failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.” Errors are unintentional and don’t necessarily result in adverse consequences. Malpractice, on the other hand, shows a lack of professional skill and by definition results in damage or injury.

In the past, says Dr. Van Ruiswyk, the most likely response to human error was to determine who was at fault and then assign blame. This method isn’t particularly productive – it doesn’t help to reduce the number of future mistakes and it encourages people to hide their slip-ups. Errors are usually the result of a series of mishaps, not the consequence of a single lapse, and today we look for more inclusive answers.

From Fault-Finding to Systems Analysis
In order to make effective changes we need to look at the system in which the errors are occurring and determine the series of events that led to the error. All systems will have errors, Dr. Van Ruiswyk explains, but in the field of medicine, events such as miscommunication between staff members or between patients and their health care providers can have serious or even fatal consequences.

Health care professionals are responding by developing systems that simplify and standardize the human side of processes, and that facilitate improved communication between health care providers and their patients. As an example, Froedtert and Medical College teams are improving data input so every patient has a “master record” that keeps track of all treatments, medications and appointments in one database that can be accessed by the members of the patient’s health care team. For patients, this means they won’t have to repeat the same personal data each time they go to a new department or clinic. For health care staff, the master record will provide up-to-date knowledge on each step of the patient’s care.

According to Dr. Van Ruiswyk, systems may improve their reliability by adopting techniques that:

• Ensure good communication
• Simplify and standardize processes
• Use “forcing functions” – procedures that won’t work until all necessary information is included
• Build redundancies into the system as fail-safe measures
• Use checklists and other aids to decision-making
• Stimulate multiple senses, for example, by using equipment that both flashes and buzzes to indicate an error
• Eliminate look-alikes and sound-alikes, e.g., use generic names for brand-name drugs such as “Celebrex” and “Celexa” that might be confused

What You Can Do To Help Ensure Safety
Despite the best efforts of the medical community and individual health care practitioners to develop perfect systems, mistakes will always happen. Fortunately there are steps that patients can take to help prevent errors in their treatment or the treatment of a loved one. The US Agency for Healthcare Research and Quality offers the following safety tips for patients:

Five Steps to Safer Health Care

1. Speak up if you have questions or concerns – your health care provider will be able to clarify explanations or instructions.
2. Keep a list of all your medicines.
3. Make sure you get the results of any tests performed.
4. Talk with your doctor about your options if you need hospital care.
5. Make sure you understand what will happen if you are having a procedure done.

“Patients should always make sure they are clear on their doctors’ instructions – how many times per day a medication is taken, for instance, or when and how they can expect to hear about test results,” Dr. Van Ruiswyk notes. “They should clearly understand the information that they are being given, and know where to find additional facts if they need them.”

Some people might be afraid to question their health care providers, but today patients are expected to take part in their health care decision-making – something they can’t do without adequate information. “Every member of the health care team wants the best possible outcome for every patient,” says Dr. Van Ruiswyk, “and our progress in patient safety will continue to improve the systems in which we work.”

Eileen Early, BA, BSN, RN
HealthLink Editor

This article contains information from:
The Field Guide to Human Error Investigations, Sidney Dekker (2002), Ashgate Publishing.
Agency for Healthcare Research and Quality, US Dept. of Health and Human Services.
To Err Is Human: Building a Safer Health System, (2000), The National Academies/Institute of Medicine.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.