Terrible cases which create the ‘headlines’ are just the ‘tip-of –the-iceberg’, two large studies, one performed in Utah and Colorado and in New York; found that adverse events occurred in 2.9 and 3.7 of hospitalizations (Kohn, 2000). When extrapolated to almost 33.6 million admissions to United States hospitals in the year 1997, the study’s results in Utah and Colorado mean that almost 44,000 Americans die every year due to medical errors, while the results of the New York Study suggest the number may be as high as 98,000, and even when using the lower estimate, deaths due to medical errors exceed the number attributable to the 8th leading cause of death (Kohn, 2000).
According to statistics, a lot of citizens die annually due to ‘medical-errors’ compare to breast cancers, vehicular accidents, or ‘AIDS’. According to Kohn, ‘medication errors’ commonly occur in hospitals and even though not all result in tangible damages but they are expensive. Similarly, according to a study performed on 2 teaching hospitals, they came to a result that almost 2 in 100 admittances suffered an avoidable unfavorable ‘drug-event’, causing an average increased cost on hospital of around $4,700 every admission or $2.8 million every year in a 700 ‘bed teaching-hospital’ (Kohn, 2000).
Based on specialist ‘James Reason’, slip-ups are based on two type of failure: either the original ‘intended-action’ is incorrect (planning-error) or the ‘correct action’ doesn’t go as planned (execution-error). According to Kohn, errors can take place in every phase in the ‘care processes’.
Not every ‘errors’ end in harm; errors that don’t end in damage are sometimes known as ‘preventable adverse events’ (Kohn, 2000). ‘Adverse-event’ is damage from ‘medical-intervention’, and not because of patient’s ‘causal conditions’.
An error may be defined as an unintended act or as an act that does not achieve its intended outcome (Cohen, 2000). According to Cohen, wide publicity has given to a series of apparently egregious errors that resulted in death or in inappropriate surgery; this, combined with the recognition that more could be done in hospitals to prevent patients injuries resulting from errors, has lead to a substantial increase both in investigations into the cause of medical errors and in the search for preventive mechanisms. On the available evidence, medical errors in UK and the USA, including those caused by drugs and their medical misuse, are responsible for the death of some 4-8 patients and injury to at least 40 to 100 patients, respectively, every hour (Naylor, 2002).
Given the intricate character of ‘medical-practice’ and the huge number of intercessions which every patient gets, a high ‘rate of error’ isn’t astounding. One of the reasons why do health professionals have difficulty dealing with human error is that, the emphasis during training on error free practice; in everyday practice, the message is equally clear: mistakes are unacceptable (Cohen, 2000). Doctors, nurses, and pharmacist are expected to function without errors, which mean that they feel ashamed and inadequate when errors inevitably occur; this striving perfection is laudable, of course, and is an important aspect of another goal of professional training: developing a sense of responsibility for the patient (Cohen, 2000). The high standards of practice that are taught to nurses, pharmacist, and doctors are often reinforced in hospital practice by unforgiving system of censure and discipline.
The relative indifference to injury and death caused by the routine use of common drugs is curious, and appears to reflect a greater interest in developing and prioritizing commercial activities, and may also reflect the lack of interest and attention directed to the problem by the media, as society cannot address a problem that is not known to exist (Naylor, 2002). In addition, the mechanism which exist for the reporting of adverse effect which exist for the reporting of adverse drug-induced events betray a voluntary and almost amateurish approach, notwithstanding a structured system.
According to Naylor, misunderstanding of the potentially unsafe nature of medication is not limited to lay people. Recently, during the design and teaching of new courses in pharmacology and therapeutics to undergraduate students in pharmacy and other healthcare disciplines, emphasis was given to the great care required in the safe use of medicines, and also to the problem of medical error.
Psychological and Human Factors Research
Human-factors specialist and cognitive psychologist have been concerned with the biology, psychology, and sociology of errors for several decades; by developing models of human cognition and studying complex environments such as airplane cockpits and nuclear power plant control rooms, they have learned a great deal about why people make errors and how to prevent them (Cohen, 2006). According to Cohen, the principles developed by experts in these fields are pertinent to redesign of health care systems to reduce errors. In simple terms there are two modes of mental functioning and those are automatic and problem solving. Most mental functioning is automatic – effortless and rapid; we don’t have to think about the process of eating or driving to work for example; these unconscious functions are performed in a parallel processing mode, and attention should only be paid when there is a change or interruption in the process (Cohen, 2006). On the other hand, problem solving requires intense mental activity; to solve problems we have to recall stored knowledge and apply rules, and in contrast to the automatic mode, problem solving thought processes are conscious, slow, and sequential, and therefore difficult.
Errors that occur when an individual is functioning in the automatic mode are called as ‘slips’ which are a usually a result from distractions or failure to pay attention to critical moments (Cohen, 2006). Another common error mechanism is called loss of activation, in which attention is distracted and a thought process is lost. According to Cohen, both physiological and psychological factors can divert attentional control and slips more likely; physiological factors include fatigue, sleep loss, alcohol, drugs, and illness while psychological factors include other activity as well as emotional states such as boredom, frustration, fear, anxiety, and anger in which all lead to preoccupations that can divert attention.
Errors of problem solving thought or mistakes are complex which includes rule-based mistakes occurring when a wrong rule is chosen, either because one misperceives the situation or applies the wrong rule or because one simply misapplies a rule; and knowledge based mistakes which occur when the problem solver confronts a situation for which he or she possesses no programmed solutions (Cohen, 2006). Errors arise because of lack of knowledge or because of misinterpretation of the problem. According to Cohen, errors can also arise from discrepancies in pattern matching which is cause by biased memory; decisions are based on what is in our memory, but memory is biased toward over-regularization and overgeneralization of the commonplace. Another aberration of thought that leads to error is the availability heuristic, a tendency to grab the first answer that comes to mind and stick with it despite evidence to the contrary. Stress is often cited as a cause of errors, although, it is often difficult to establish a causal link between stress and specific accidents, there is little question that both slips and mistakes are increased when people are under stress.
Methods to Improve Medical Safety
Labors to develop ‘medication safety’ are done in all health care systems’ levels: through assisting the patient to evade ‘medication errors’; by managing ‘health-care units’ for care to be carried safely; by building ‘health-care organizations’ that promote ‘safe care’ by training for ‘health-care workers’; and through persuading ‘health-care organizations’ to convey ‘safe care’ by ways as fiscal measures and regulatory (Aspden, 2006).
Since 1980s, ‘Peoples Medical Society’ has extended strategies to assist consumers in avoiding ‘medication errors’ at mail-order pharmacies and community, and in hospitals. For more than a decade, many organizations have provided guidance on safe medication practices for health care delivery units; also, from 1994, the ‘Institute for Safe Medication Practices’ has offered assistance on removing ‘medication-errors’ through journals, newsletters, communications, and articles with ‘regulatory authorities’ and ‘health-care professionals’. According to Aspden, technologies’ full benefits in avoiding ‘medication errors’ wont be attained except a ‘culture of safety’ is built inside ‘health-care organizations’ which are sufficiently operated with professionals whose skills, knowledge, and ethics make them able of managing patient’s ‘medication management’ who are unable and vulnerable to administer their medications ‘proficiently themselves’. Many essential systems such as information technology, accreditation, knowledge generation, and education promoted secure ‘medication use’.
Causes of Medication Errors
Most health care professionals have learned the ‘five rights” of safe medication use: the right patient, right drug, right time, right dose, and right route of administration, yet even when practitioners believed that they have verified these rights, errors, including fatal ones, occur (Cohen, 2006). One of the reasons for such errors is that health professionals may have difficulty putting the five rights into practice. The five rights focus on individual performance and overlook crucial system components that contribute to errors; for example, poor lighting inadequate staffing patterns, poorly designed medical devices, handwritten orders, dozes with trailing zeroes, and ambiguous drug labels can prevent health care professionals from verifying the five rights, despite their best efforts (Cohen, 2006).
Understanding the Causes and Cost of Medication Errors
Many factors in ‘health-care system’ add to medication errors and safety; a few of these factors can be credited straightforwardly to ‘provider organizations’, while the others can be credited to ‘medication-use system’ itself (Aspden, 2006).
A Denver hospital in 1996, admits that a ‘medication-error’ had caused to death of a ‘day-old infant’, from a mother with previous syphilis record; since the child’s parents only spoke ‘Spanish’, disease treatment couldn’t be easily confirmed (Aspden, 2006). In spite of ‘imperfect information’ of the parent’s ‘past treatment’ of syphilis and the present condition of both the infant and mother, a judgment was done to take care of the child for ‘congenital syphilis’, but an error occurred during the medication process, wrong prescription dose was given and a wrong route of entry of the drug has been made causing the infant to die. The 3 nurses engaged on this ‘medication error’ shortly arraigned by a ‘grand-jury’ for ‘negligent homicide’ (Aspden, 2006). According to Aspden, the experts advised against the tendency to focus on the errors of the providers, and because mainly of what people do is managed by the ‘system within which they act’, the reasons of errors are due to the ‘system’ and frequently lie remote the individuals’ control, in spite of their finest labors.
A System Approach
According to Cohen, where medication errors are concerned, finding out who was involved is less important than learning what went wrong, how, and why. In a study conducted, the ‘proximal causes” of medication errors includes: lack of knowledge of the drug, lack of information about the patients, violations of rules, slips and memory lapses, transcription errors, faulty identity checking, faulty interaction with other services, faulty dose checking, infusion pump and parenteral delivery problems, preparation errors, and lack of standardization.
System Elements Implicated in Errors
The system-based causes of errors can be best uncovered through interdisciplinary efforts since they steam from weaknesses in systems throughout an organization. When a medication occurs, organization wide system weaknesses are of ten identified in: how information is collected and communicated; how colleagues interact; how patients and staff are educated; how the organizational culture and physical environment are managed, how staff is provided to carry out patient care functions, how staff learn about system errors and their causes; and how patients are safeguard from harm.
Ten key system elements that have the greatest influence on medication use have been identified and those include: patient information; drug information; communication related to medications; drug labeling, packaging, and nomenclature; drug standardization, storage, and distribution; medication delivery device acquisition, use, and monitoring; environmental factors; staff competency; and education; patient education; and quality processes and risk management (Cohen, 2006).
Medication Error Reporting Systems
Providing the best possible patient care in a safe, compassionate environment is a common goal for health professionals. Error reporting systems promote this goal by helping health professionals, organizations, and safety agencies learn about: potential risk or risk hidden in the process used to provide patient care; actual errors or errors that occur during patient care; causes of errors or the underlying weaknesses in the system and processes of care that explain why an error happened; and prevention, ways of preventing recurrent events and, ultimately, patient harm. Error reporting programs must be an essential part of any strategy to reduce injuries during patient care, because understanding the types of injuries and their causes is the key to the development of effective preventive measures.
UK Litigation Process as a Potent Tool to Influence Errors and Complaints
Complaints are caused by misdiagnosis and substandard care; however, most complaints are about communication with and the behavior of the doctors. According to Naylor, the three commonest complaints by patients are that doctors fail to: listen to what the patient is saying about their personal circumstances and illness; explain in simple and clear language the diagnosis, treatment and associated risk; and discuss an unsatisfactory result.
The patient needs to know what happened, to seek apology for what happened, and to seek reassurance that it will not happen again. A defensive attitude by the doctor leads to resentment and this as much as any other factor leads to litigation (Naylor, 2002). According to Naylor, half of all complaints against general practitioners are due to systems failures rather than to clinical error; a timely and comprehensive response reduces the likelihood of litigation.
The New Civil Procedure Rule (CPR)
In 1994, Lord Woolf appointed to review the rules and procedures of the civil courts of England and Wales with respect to negligence, and through this, the major aims includes, improve justice and reduce the cost of litigation; to reduce the complexity of rules and simplify terminology; and to remove unnecessary distinctions of practice and procedure.
Litigation, Negligence and Criminal Law
The increasingly factor that will hold academic teaching accountable for the quality of its provision is litigation. Errors committed in healthcare, particularly those committed by trainee healthcare students, may increasingly call into question the adequacy of undergraduate course provision and/or clinical supervision (Naylor, 2002).
Litigation may be increasingly important in holding the academic and clinical professions accountable for their profession. Even a preregistration pharmacy trainee (and his supervisor) in the UK was subject to a police prosecution and criminal charge; this reflects major and increasing concern about the standards of medical care and legal redress (Naylor, 2002).
According to Naylor, legal negligence requires evidence of a duty of care, breach of that duty, and loss caused or materially contributed to that breach. In some countries the criminal law is routinely used to assess medical negligence. Reckless behavior or gross negligence is at the heart of manslaughter charge, and its seed may be sown in complacency and arrogance. Both can begin to be addressed at the undergraduate level and in the ethical training, and before incompetence is revealed on the very public stage of a criminal court, to tarnish the entire profession.
Frustration may have driven the new initiatives of prosecution through a the criminal justice system to ensure that patient seek a just and fair remedy, however, whether this will be achieved using criminal proceeding remains to be seen.
The Changing Face of Negligence
In a judgment of 1954, two men were recorded to have suffered injuries after receiving spinal anesthetics. For both the patient and the doctor the distinction is fundamental. An injury arising from negligence will carry an attribution of blame to the doctor and the possibility of the patient having a right compensation; neither necessarily follows from misadventure. According Naylor, in determining the possibility of negligence following an act or omission by a doctor, one applies the following: such as a duty of care; breach of that duty; and the loss caused or materially contributed to that breach.
There must be a synthesis of all three factors to generate the legal definition of negligence. It is quite possible for a doctor to be negligent in the usual sense of the word , but due to good luck the patients escapes the harm, does not suffer loss, and therefore the act is not one of legal negligence. Therefore the crucial task is for the court to distinguish between negligence and misadventure which hinges on a breach of duty of care.
Reckless behavior or gross negligence is at the heart of a manslaughter charge, and its seeds may be sown in complacency and arrogance (Naylor, 2002). There is evidence that the inept not only reach erroneous conclusions but also overestimates their abilities; however, in the case of physicians, complacency and arrogance may conspire with an absence of knowledge and understanding or lack of skills, with a tragic outcome.
Clearly there are major and increasing concerns about the standards of medical care and legal redress. Frustration may have driven the new initiatives of prosecution through the criminal justice system to ensure that patients may seek a just and fairly remedy (Naylor, 2002). However whether this will be achieved using criminal proceedings remains to be seen, although this is the normal practice in some European countries.
Nevertheless, important principles emerge from some of the above prosecutions that are relevant to education and healthcare. According to Naylor, the prosecution of the pharmacy preregistration student and his clinical tutor for dispensing of a lethal medication gave rise to numerous articles and correspondence within the pharmaceutical press which questioned the teaching of pharmacy undergraduates, where ‘academics must shoulder some of the blame’.
Increasingly, the public perception of the stature of the professions is being driven by the media in reporting catastrophic events and the most regrettable behavior of the professions’ least able or most notorious members (Naylor, 2002). Attempts to recognize prevent or neutralize professional incompetence and malfeasance at an early stage are a crucial goal with regard to patient safety (Naylor, 2002). According to Naylor, a strong case could be made that this should commence at the beginning of education and professional instruction and addressed as a concordance with the support of the appropriate accreditation/professional buddies, future employers and patient and carrier groups.
Much can be learned from the analysis of errors, every undesirable events ending in death or grave injuries must be appraised to evaluate if the delivery system improvement can be done to minimize the probability of same events happening in future. Errors that don’t result to damage also embody an essential chance to recognize ‘system improvements’ having the probability to stop the ‘adverse events’ (Kohn, 2000). Inhibiting errors means scheming the ‘health-care system’ in every levels to make it much secured; constructing security into ‘processes of care’ is a much efficient means to minimize errors than criticizing individuals. The focus must shift from blaming individuals for past errors by designing safety into the system but this does not mean that individuals can be careless, people must still be vigilant and held responsible for their actions, but when an mistake happens, blaming individual does small in making the system more secure and stop someone else from executing similar error (Kohn, 2000).
Aspden, P. (2006). Preventing Medication Errors. New York: National Academies Press.
Cohen, M. R.. (2006). Medication Errors. New York: American Pharmacist Association.
Cohen, M. R. (2000). Medication Errors: Causes, Prevention, and Risk Management. New York: Jones & Bartlett Publishers.
Kohn, L. T., Corrigan, J., & Donaldson, M. S. (2000). To Err Is a Human: Building a Safer Health System . New York: National Academies Press.
Naylor, R. J. (2002). Medication Errors: Lessons for Education and Healthcare. New York: Radcliffe Publishing