Patient Safety And The Medical Errors

Root Cause Analysis (RCA) is a controlled method used to analyze serious adverse events. Originally developed to analyze industrial accidents, RCA is now commonly organized as an error investigation tool in health care. A principal theory of RCA is to identify fundamental problems that increase the probability of errors while avoiding the trap of focusing on mistakes by individuals. RCA thus uses the systems approach to identify both active errors: errors occurring at the point of interface between humans and a complex system and dormant errors: the hidden problems within health care systems that contribute to adverse events. It is one of the most widely used methods for detecting safety

One of the most critical factors which contribute to the number of preventable cases of healthcare harm is the culture of silence surrounding these cases. The fear of medical providers to report incidences is related to the possibility of punishment and liability due to a medical error (Discovery, 2010). The criminalization of some acts of medical error has resulted in job dismissal, criminal charges and jail time for some healthcare workers. This is despite the fact that the system they are working in helped to create the situation which led to the error in the first place. Human error, due to fatigue and system errors can result in deadly consequences, but by criminalizing the error it effectively shuts down the ability to correct the root problem. Healthcare workers, working at all levels within the medical system, can provide valuable input on how to improve the processes and prevent harm from occurring (Discovery, 2010).

The main objective of healthcare professionals is to provide the best quality of patient care and the highest level of patient safety. To achieve that objective, there are many organizations that help improve the quality of care. One of the best examples is the Joint Commission. Unfortunately, the healthcare system is not free from total risks. In healthcare activities, there are possible errors, mistakes, near miss and adverse events. All of those negative events are preventable. But, it is clear that errors caused in healthcare result in thousands of deaths in the United States.

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

The first step of the analysis is to collect data which will help with the understanding of the events. Identifying what data to collect and how and what to compare the results can be challenging. The organization should have a baseline to compare to see how the changes are working. Comparing information to similar organizations through benchmarking may indicate the success of the organization or program. Ransom, Joshi, Nash and Ransom (2008) state “benchmarking compares processes and success through gap analysis, process variation & organizational opportunities for improvement” (pg. 132). Data can be collected from prior litigations and claims information. Monitoring the information through monthly reports can indicate if process modifications or changes are needed. Once information is identified immediate action should be taken to ensure patient safety and minimize risk.

Each year medical errors cause more than 400,000 American deaths and at least 10-20 times that number experience serious harm. Researchers say that is equivalent to “three 747 airplanes crashing each day.” Medical errors rank as the third-leading cause of death in America. Therefore, patient safety is a national concern.

The provided scenario gives an account of a busy emergency department with competent staff, and the multiple errors that led up to the most severe error possible in healthcare, unnecessary death of a patient. A root cause analysis (RCA) can be utilized to help understand the systems at fault within the facility so that improvements can be determined and implemented to prevent any future occurrences (Cherry, 456). RCAs focus on systems rather than blaming individuals involved, therefore they are only appropriate in cases where there has been no willful negligence or criminal acts (Huber & Ogrinc, 2014). The overall purpose of RCAs is to find out the causes of the adverse event and determine how to keep similar errors from

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).

It is estimated that nearly 100,000 people die each year from medical errors in hospitals, with an estimated cost of between $17 and $29 billion per year. Finding a solution to this crisis has become a priority for every healthcare organization, with the realization that most errors are not caused by reckless staff, but by poor systems and processes (Institute of Medicine, 2000). Consequently, healthcare has begun to look to outside organizations in order to find solutions, by examining industries that are considered highly reliable, despite operating in hazardous situations. The lessons learned by these Highly Reliable Organizations (HROs) can be used to promote safe and reliable performance, which in turn should improve patient and staff

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.”

The IOM’s report “To Err is Human: Building a Safer Health System” shocked the health care world and made change necessary. “To Err is Human: Building a Safer Health System” released information that reported that tens of thousands of Americans were dying each year from errors (IOM, 1999). Patient safety moved to the forefront in healthcare like never before and directives were discussed to put quality as a

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

The changes in healthcare over the last several years have been dramatic. All parties, providers, insurers, and the Federal Government are looking for ways to reduce cost and increase quality. The report by the Institute for Medicine in 1999, “To Err is Human” spurred increasing scrutiny in medical care to improve quality at same and looking for ways to reduce risk to patients and increase safety. Discussion of solutions

A root cause analysis (RCA), an organized protocol or procedure, institutes a means of analyzing a sentinel or adverse event that occurs within a healthcare facility, ultimately uncovering causes of problems or errors. U.S. hospitals are required to keep confidential records within the facility of adverse reactions, yet RCAs are mandated to accompany a reported sentinel event to the accreditation organization, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and other organizations (AHRQ 2014). Various members from all aspects of the hospital form a multidisciplinary team to analyze, evaluate, and resolve errors with the goal of prevention of future adverse, sentinel events. A RCA allows for concentration on events and underlying problems that contributed to the incident rather than focusing on individual actions and behaviors (AHRQ 2012).