Clinical Errors

One of the recommendations for healthcare organizations to employ in an effort to reduce the number of errors is to advocate for voluntary error reporting nationally while conducting research and developing tools for patient safety. This way, information about errors can be gathered and prevented from reoccurring at health care sites and by health care providers. Voluntary error reporting will act as a warning of potential or actual errors and suggest ways to avoid them in the future.

It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).

Causes of major medical errors have many different factors and influences. This includes why the patient was being seen to allow such an error, what medical guideline or guideline’s that where not followed that caused the error, what could have been done by staff members to prevent the error, etc. When errors take place, repercussions follow such as the cost incurred to the patient or patient family members, fines the medical worker must pay, and most importantly what is the patients status/prognosis. Not all patients prevail and make it through such awful medical errors.

Proper patient identification in hospitals has been an issue for many years, especially when it comes to blood specimen collection. Laboratory specimens being mislabeled are a everyday cause of harm to patients including repeat diagnostic procedures; repeat phlebotomy; delays in necessary surgical procedures; a performing unnecessary surgical procedures (Dunn and Moga, 2010). This is not only costly, but it is very stressing to patients and medical staff. The biggest concern is the possibility of making a fatal error when it comes to specimen collection. Without proper patient identification this risk increases substantially. Wallin, Sodberg, Van Guelpen, Stenlund, Grankvist, and Brulin (2009) state that critical errors in patient identification for blood testing occurs in up to one per 1000 specimens or procedures and misidentified specimens cause 160,000 adverse events every year in America.

The College of American Pathologists or CAP is the accrediting organization for laboratory and testing personnel. CAP’s “accreditation process is so thorough, the Joint Commission [and CMS] accepts …their standards” in place of conducting their own survey of the hospital’s laboratory and personnel (Gartee, 2011, p. 47). This is because of the guidelines they follow to maintain their integrity and to remain the industry standard. In recent years, the “CAP [has] developed new check list” for continued improvements. Additionally, they are continuing to vet the requirements for the new next-generation sequencing or NGC-based test that is speeding laboratory procedures. So much so that the recent adoption of the new technology for clinical testing” was done prior to the new standards being approved (Aziz, et.al. 2015, p. 481).

The third leading cause of death in America may surprise you. Hospitals and healthcare organizations dedicate their branding to reflect a place of hope, comfort, and healing when ones health is compromised. Sadly, medical errors do exists in the realm of healthcare. The National Center for Biotechnology Information defines medical error as “an act of omission or commission in planning or execution that contributes to or could contribute to an unintended result.” Medical errors may include incorrect record keeping, administering incorrect medication to a patient, misdiagnosis, failing to remove all surgical instruments and performing surgery on the incorrect site. The Agency for Healthcare Research and Quality identified eight factors that contribute to the cause of medical errors. These factors include “communication problems, inadequate information flow, human problems, patient-related issues, organizational transfer of knowledge, staffing patterns, technical failures and inadequate policies and procedures.”

Nothing is perfect in this world. The mistake is inevitable, whether it be at school or in a workplace, one will always be able to find error nestled somewhere in the system. Because of its inevitability, an error is also very prominent in science, specifically in medicine.

Medical errors have adverse effect on health care organization structure because it put a question mark on health profession’s reputation. The medical error definitely can cause harm to the patient or even the death. Medical errors can happen anywhere in healthcare system: in hospitals, clinics, surgery rooms. Medical mistakes can arise from doctors, nurses, surgeons, hospital administration, and many others. Medical errors affect the health care organizational structure, culture, and social in many ways. Medication errors have severe direct and indirect effects on health care organizational structure, and culture is usually the outcome of breakdowns in a system of care. Many reasons can involve in medical errors such as, miscommunication

In 1999, the Institute of Medicine (IOM) “Too Err is Human” estimated 98,000 deaths yearly due to medical error. Many of the errors are the result of adverse drug events, most of which occur during the prescribing and administration stages of medication administration (Guo, Iribarren, Kapsandoy, Perri, and Staggers, 2011). These errors are a significant cause of morbidity and mortality in hospitalized patients. One report estimates that when all types of errors are accounted for, every hospitalized patient can expect on average one type of medication error per day and during 2006, adverse drug events resulted in approximately 400,000 cases of error at a cost of over $3.5 billion (pp. 202-224). Studies have demonstrated a

Congress held hearings at which people who had been harmed by laboratory errors testified. These hearings revealed serious deficits in the quality of work from physician office laboratories and in Pap smear testing results (R. D. Feld, M. Schwabbauer, and J. D. Olson, 2001, The Clinical Laboratory Improvement Act [CLIA] and the physician's office laboratory; Virtual Hospital, University of Iowa College of Medi-cine [www.vh.org/adult/provider/pathology/CLIA/CLIAHP.html]). In 1988, Congress once again responded to public concerns about the quality of laboratory testing by passing CLIA '88. CLIA '88 expanded the laboratory standards set by CLIA '67 and extended them to include any facility performing a clinical test. Currently, under CLIA '88,

The preanalytical errors increases health care costs and decreases the patient satisfaction. The laboratory errors that happen at any stage of the total testing process have influence on quality of laboratory services. Any errors that happen during this total testing process will affect the patient care that also includes unnecessary recollection of samples, delay in reporting, misdiagnosis and treatment by the clinician. Although the errors can happen at any stage of the total testing process, preanalytical errors accounts for highest percentage (70%). The consequences associated with analytical errors are significantly reduced by the use of modern laboratory instruments. But pre analytical phase is still prone to more errors due to its complexity and different stages that involved within and outside laboratory. The inaccurate reporting of results due to preanalytical errors leads to unnecessary investigations and creating an additional burden to the healthcare system (Kaushik, & Green, 2014). According to Green (2013) the healthcare economist created a model to quantify the costs associated with laboratory errors and poor sample quality. It is based on operating costs, number of beds, test volume, number of rejected samples, instrument problems and the frequency of inaccurate results reported by laboratory and their impacts. As per this model

Consults with physicians, hospital personnel and independent and hospital laboratory personnel regarding common laboratory problems.

Errors in medicine are unfortunately plentiful, and are also oftentimes preventable. Even with technology, regulations, and procedures designed to improve health care and reduce errors, the occurrences are still much too high. Recent statistics from the World Health Organization show that 10% of hospitalized patients are harmed during their stay, and 1.4 million people at any time are suffering from hospital-acquired infections. It is estimated that when it comes to surgical care, 50% of associated complications are preventable (WHO). There are always ways to improve how tasks are performed in hospitals, and studying recent incidents can help us

“No employee makes the same mistake twice. He is fired the first time.” This seems so harsh, right? Imagine not being able to make any mistake without losing your job. Obviously, there are mistakes that are made that do merit losing your job. There have been mistakes made by people that costed their employer millions of dollars; but is it too much when any mistake results in the loss of employment? This makes you think though, if people knew they’d be fired after their first mistake, you feel like they’d work harder to make sure they don’t make that mistake. This also raises the question of whether this would either positively or negatively affect the company.

According to the IBMS Point of care testing (Near patient Testing) guidance on the Involvement of the clinical laboratory, Near patient testing describes the “analytical procedures performed by patients by health care professionals outside the conventional laboratory”. This is due to the advance in technology and the convenience of carrying to tests in locations such as operating theatres, hospital wards and general practice surgeries in primary care.