Medical Error

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.

Healthcare workers are not the only ones fearful of exposing medical errors. The medical institutes themselves operate behind a wall of silence. The IOM first recommended a national medical error reporting system in 1999 and despite attempts by then President Clinton, the American Medical Association and the American Hospital Association successfully lobbied against it (Dyess, 2009). As of 2009, only 20 states have a mandatory medical error reporting system and only a fraction of estimated

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).

Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency

Blendon, R. DesRoches, C. Brodie, M., Benson, J. Rosen, A., & Schneider, A. (2002). Views of practicing physicians and the public on medical errors. New England Journal of Medicine. 347, 1933-1940.

The Institute of Medicine released a report in 1999 titled To Err is Human: Building a Safer Health Care System concerning the number of medical error related deaths. The report states that between 44,000 and 98,000 medical error related deaths occur each year in hospitals across the country (Kohn, L. T., Corrigan, J., & Donaldson, M. S., 2000) In response to this report, the Institute of Medicine released Crossing the Quality Chasm: Health: A New Health Care System for the 21st Century that outlines six aims for the future of the healthcare system: safe, effective, patient-centered, timely, efficient, equitable (Institute of Medicine, 2001). These aims set to establish the quality of healthcare across the country. Quality is defined by the Institute of Medicine as ““the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (2001).

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.”

According to the article, the economics of health care quality and medical errors, in 2008 medical errors costs the United States $19.5 billion. It goes without saying that this a huge problem. It’s relieving to know that we are aware of several adverse detection (AE) methods such as voluntary or incident reporting, medical record review, administrative surveillance, clinical observation, and electronic health record surveillance. Voluntary reporting is the most common but unreliable way of detecting adverse events. It depends on the physician reporting and admitting that an adverse outcome as occurred. However, it has been shown to underestimate adverse events by a factor of 50 and often identifies issues other than true safety

According to the Institute of Medicine (IOM) report, To Err Is Human, the majority of medical errors result from faulty systems and processes, not individuals (Hughes, 2008). However, due to processes that are inefficient and variable, multiple health insurance, differences in provider education and experience, and other factors that contribute to the complexity of health care the IOM has put together six aims of health care that is effective, safe, patient-centered, timely, efficient, and equitable (Hughes, 2008).

The book explains that vast majority of errors occur due to good doctors trying to do the right thing but being unable to reach the goal since the system is fragmented. The authors include many instances of medical error, responses from patients, families, and healthcare professional, and the steps taken to improve the performance and reinvent the health care system. Throughout the book, heroic role of many leaders of healthcare professionals, scientists, and academic professionals are presented.

Health care quality and patient safety emerge as top priorities at the start of the millennium. In 2000, the Institute of Medicine (IOM) published the report “To Err Is Human: Building a

In the periodical Medical Errors: Where are We Now it says that a study that was conducted showed that only thirty percent of the patients were told about their medical errors. (Mewshaw, White, Walrath. p. 51)

Wrong site, wrong procedure, and wrong patient errors are avoidable safety issues. Nearly 1.9 trillion dollars are spent on medical errors each year in the United States (Catalano & Fickenscher, 2008). Between 1995 and 2007, 691 wrong-site surgeries have been reported to The Joint Commission's Sentinel Event data repository (AHC Media LLC, 2008). In 2003 in response to the outcry for better patient safety The Joint Commission

In today's modern world with plenty of technology, it is hard to believe that we cannot figure out how to reduce Medical errors. The issue of medical error is not new in health care organizations. It has been in spot light since 1990's, when government did research on sudden increase in number of death in the hospitals. According to Lester, H., & Tritter, J. (2001), "Medical error is an actual or potential serious lapse in the standard of care provided to a patient, or harm caused to a patient through the performance of a health service or health care professional." Medical errors

Reporting errors can strengthen the processes of care and also enhance the quality of care. To effectively avoid further errors that can cause harm to patients, improvements must be made on the incidents or events reported in reporting system. Reporting errors can help the organizations better understand what happened, identify the factors that cause the occurrence of errors or incidents, determine its frequency and predict whether it could happen again and find an intervention to prevent or to