Medical errors 07.04.2021

Medical errors

1. Medical errors Dr. Shazia Iqbal  Assistant Professor Director of Medical Vision College of Medicine, Riyadh [email protected] View my Linkedin Profile https://www.researchgate.net/profile/Shazia_Iqbal7 https://orcid.org/0000-0003-4890-5864

2. • Discuss What are medical errors • Enlist Types of medical errors • Discuss Why medical errors happens • Discuss Should we tell truth to the patient • Discuss How can we reduce errors in the health profession Objectives

3. An error An error is ‘something incorrectly done through ignorance or inadvertence; a mistake, e.g. in calculation, judgement, speech, writing, action, etc. or ‘a failure to complete a planned action as intended, or the use of an incorrect plan of action to achieve a given aim. Medical Error Is the failure in the treatment process that leads to, or has the potential to lead to, harm to the patient. Near Miss: incidence about to happen but by chance didn't occur. Sentinel event: A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury. Definition

4. Types of medical errors

5. Causes of medical errors 1- Complexity of healthcare The interaction of drugs with complex technologies. Staying in hospital for long periods of time. Multidisciplinary approach 2- System and process design Inadequate communication Unclear lines of authority

6. Causes of medical errors 3- Environmental factors. Services congestion unsafe care provision areas poorly designed areas for safe monitoring. 4- Infrastructure failure. Lack of documentation process Lack of continuous improvement process

7. Causes of medical errors 5- Human factors and work environment

8. Costs of a Medical Error IOM in 1999 issued a report estimating total costs (including the expense of additional care necessitated by the errors, lost income and household productivity, and disability) of between $17 billion and $29 billion per year in hospitals nationwide. Medication Errors each preventable adverse drug event that took place in a hospital added about $8,750 (2006 dollars) to the cost of a hospital stay. 400,000 of these events occur each year (IOM, 2006)

9. Fixing Healthcare All healthcare schools should educate about medical errors Prevention Disclosure Understanding themselves Emotional support needs to be available Clear definition of medical error Basis for reporting across America Make reporting mandatory Use and “error investigation team”

10. Websites of Interest Agency for Health Care Research and Quality: http://www.ahrq.gov/ Oregon Patient Safety Commission: http://www.oregon.gov/OPSC/index.shtml

11. After an Error Occurs Patient faces a lack of productivity, loss of quality of life, depression, traumatization and may increase their fear of an error in the future. What about the health care provider? Physicians felt upset and guilty about harming the patient, disappointed about failing to practice medicine to their own high standards, fearful about a possible lawsuit and anxious about the error’s repercussions regarding their reputation (Gallagher et al., 2003). Physicians struggle with forgiving themselves for what happened and some turned to a trusted colleague, significant other or the affected patient to seek forgiveness through disclosure (Gallagher et al., 2003).

12. Tell the truth Notify your professional insurer and seek assistance from those who might help you with disclosure (e.g., unit director, risk manager). Disclose promptly what you know about the event. Concentrate on what happened and the possible consequences. Take the lead in disclosure; don't wait for the patient to ask Offer the option of follow - up meetings. Be prepared for strong emotions. Accept responsibility for outcomes, but avoid attributions of blame. Apologies and expressions of sorrow are appropriate.

13. Actions to reduce medical errors • Greater focus on healthcare quality (performance measures / clinical reviews / quality in healthcare research) • Mandatory accreditation process • Patient safety standards / targets Computerized drug ordering systems Reporting errors should be voluntary and confidential insurance against malpractice Patient education

14. references https://pubmed.ncbi.nlm.nih.gov/29763131/ https://www.uofmhealth.org/health-library/meder https://academic.oup.com/qjmed/article/102/8/513/1598923 https://www.nccmerp.org/about-medication-errors https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3211566/

15. thank you