Medical Errors: A Story Of How Not All Hospitals Are The Same
Society has a zero-tolerance policy for plane crashes.
If a plane crashes, it is in the news. Investigations are conducted, the cause of the crash is found, individuals and corporations are held liable, and policies are put in place to prevent it from happening again.
However, car crashes are another story. Depending on the magnitude of the crash, it might be on the local news channel, but most often, car crashes are glossed over. As a society, we have adopted a paradigm in which we view car crashes as a cost for a very convenient method of transportation.
Hospitals view medical errors in the same way.
Some view them as a cost of healthcare and disease, in which risk outweighs opportunity. A situation that is out of their control. Some take risk and preventability more seriously than others. They investigate, break down, and figure out what steps must be taken in order to eliminate that risk. They have a zero-tolerance policy for any preventable error.
We hear about cancer, heart disease, and respiratory diseases as being some of the leading causes of death in the United States. But we rarely hear about medical errors and the impact they have on society; caused not only by human error but also through systemic failures within hospitals.
According to a study by Johns Hopkins in 2016, an estimated 250,000 Americans every year die due to medical error in the United States, surpassing the CDC’s leading cause of death; respiratory disease. However, only 10% of medical errors are reported as medical errors.
For more context on medical errors & a real world case study, I would highly recommend watching this video from Vox, titled Do no harm: Some hospitals let a preventable infection kill their patients
Many medical errors are not necessarily due to bad doctors. Surgeons aren’t out to get you. However, the mistakes are representative of vast systemic issues, from poorly coordinated care to unwanted variations in physician practice patterns, to simply the wrong attitude towards risk and prevention.
Looking at medical errors through a systematic approach allows us to better differentiate the difference between active failures and latent conditions.
Active failures are errors and violations committed by people on the sharp end of the system; including pharmacists, nurses, and surgeons. On the other hand, latent conditions are fallible decisions made by the higher management in an organization, whether that be policymakers, regulators, or those designing communication and structure.
Latent conditions lead to weaknesses in the defenses of any organization, including a hospital. They increase the probability that when active failures occur, they will combine with existing foundational weaknesses and result in a much more serious consequence.
Hospitals are carefully safeguarded places. They house individuals whose lives are at stake at any given moment. When alignments across several systems, from communication to treatment, to basic care are neglected or disrupted, the probability of a critical event or death occurring increases by more than a marginal amount.
The various ways through which medical errors occur are immensely complex. They range from misdiagnoses to variation in procedures, to a simple mistake, such as a miscalculation or a moment of distraction, on the part of any authority within a hospital. However, it is difficult to understand the distribution of these errors as we rarely document these errors as “errors,” and instead report them as the result of these errors, such as a “central line infection.”
Adverse Drug Events, or ADEs, are one of the most prevalent forms of medical errors. They are defined as “…injury resulting from a medical intervention relating to a drug.”
ADEs consist of errors within four steps of the drug transmission process; prescription, transcription, dispensing, and administration.
Within prescription, errors range from providing individuals with the wrong dose, such as calculating a chemotherapy dosage based on the patient’s previous weight, causing the dose to be too high, to providing patients with drugs that interact poorly with another known drug being taken by a patient.
In transcription, errors usually arise in miscommunication, as providers might omit key information when describing how a procedure should be carried out to re-writing dosages, frequencies, routes of exposure, or timings incorrectly.
Furthermore, errors in the dispensing of drugs might occur through the incorrect preparation of drugs, expired drugs, or labeling errors. And errors in the administration of drugs might occur through a plethora of causes, from administering drugs through the wrong route, such as intrathecally instead of intravenously, to the incorrect frequency of drug provided to the patient.
In 1995, a study showed that 49% of errors occurred in the drug ordering stage (i.e. prescribing), 11% in transcription, 14% in dispensing, and 26% in administration. The most frequent types of errors in the drug prescribing stage were wrong dose, wrong frequency, wrong choice, and known allergy.
Research also suggests that a significant proportion of ADEs are caused by multiple errors occurring at different points of the drug delivery process. For example, 21% of ADEs in one study resulted from failures at multiple stages in the drug administration process.
In general, we can identify over a dozen main sources of system failures leading to ADEs; factors pertaining to the organization and the processes within it, which increase the likelihood that clinicians and nurses will make errors. Some of these include:
- dose and identity checking
- medication prescription tracking
- interservice communication
- standardization of doses and frequencies
- standardization of drug distribution in a unit
- lack of uniform procedures
- preparation of intravenous medications by nurses
- staffing and work assignments
Even within adverse drug events, many failures cannot be completely attributed to human error; systematic failures play a larger role than they seem to, especially in points of communication between healthcare professions, departments, or wards; the lack of electronic records and other automated systems; and poor hospital design.
However, ADEs represent an issue as we can act upon by making simple changes within organizations, such as emphasizing potential drug errors to healthcare providers and standardizing prescribing language within and between hospitals, to larger and more systematic ones, such as improving the drug delivery system to have as many independent checks as possible (e.g. independent calculation checks by the prescribing physician, pharmacist, and nurse).
ADEs are just one part of the story. Countless other systematic failures manifest in dozens of medical errors, from misdiagnoses to the lack of electronic health records, to the underreporting of errors.
Even economically, medical errors would reduce an enormous cost in healthcare. Even the most conservative estimates show that medical errors in the United States alone cost 20 billion USD per year. And these are just the errors that are logged, due to some form of malpractice.
This is one of the most impactful times in history to combat this issue, as the COVID-19 pandemic further induces many of these errors as we are in a time of crisis. Hospitals are consistently trying to rationalize care and are unable to take in all of the patients that are seeking help, and states including Idaho and Alaska have activated crisis standards of care, during which healthcare is “rationalized” in order to save the most possible lives.
In the absence of the pandemic, there are approximately 96,000 ICU visits a week, but there are an additional 23,000 visits just due to COVID-specific cases.
Medical errors are seven times more likely to happen in the ICU, where doctors and nurses are working extended hours, there is more variability in procedures due to emergencies, and COVID adds an extra burden on top of that. Procedures go unfollowed, cracks start to emerge, and huge problems start to arise.
Some hospitals look at medical errors as an inevitable tragedy, instead of adopting a zero-tolerance mentality towards them. While some hospitals simply acknowledge that any disease comes with risks, that the situation was not in their control, and list the death as an accident, some hospitals stand their ground.
They pick apart the situation, understand what it would take to eliminate any and all possible risk, and refuse to accept “good enough.”
They pick apart every misdiagnosis, every infection, every turn of events that had even a margin of preventability, and figure out what went wrong.
They set a standard through which they don’t want things to go right, but they’ve taken all the measures to expect them to go right.
As a society, we must adopt better consensus protocols to streamline the coordination between doctors, the delivery of medicine, and the reduction of variability in treatment. In an era of automated healthcare and digital systems, we can also improve medical errors by making these tools more accessible to improve communication, standardize procedures, and more closely track patient information.
Through doing so, we can not only begin to acknowledge these errors but make systematic changes as a society in a wider range of hospitals to improve upon them.
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