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Defining a medical error.

Medical errors are very popular in mass media. They cover newspaper front pages and make simple people lose their trust in health professionals and mainly in doctors. Patients have always been seeing doctors as magicians. They really don't think about the possibility of having a bad outcome during their therapy. They cannot imagine that they will suffer from a complication after an operation. They usually do not want to accept the possibility of death for their beloved person who is admitted in the Hospital. Thus, medical errors should firstly be seen as unexpected events.

Medical errors are unexpected by many doctors, too. Most doctors believe that their patient will be successfully treated after his operation, will not present a complication and will certainly not die. This belief makes medical complications become unexpected by medical doctors, too. The problem is that if you do not think about the complication, you may also not search for it. If you do not search for complications, then you may discover them later than normal!

If medical errors were not considered unexpected by both medical doctors and patients, then things would be more simple. For example, many patients are fond of operations because they like to participate to medical interventions, even with the role of the patient. This is a very common sport of people with hysterical personalities. On the other hand, many medical doctors are fond of unneeded operations either for raising their earnings or for teaching more trainees in the operating theatre or because they think that their intervention/surgery cannot harm the patient and thus it is equal to a non interventional treatment. If medical interventions were limited to the needed ones only, then medical errors would be counted to the absolutely smallest number.

What is a medical error? This should be clear for medical doctors and patients. Because sometimes we both professionals and patients do not know what is a medical error. The QuIC (Quality Interagency Coordination Task Force) (1) expanded the IOM's (Institute of Medicine of the National Academies of US) (2) working definition of a medical error to cover as many types of errors as possible. Their definition of a medical error is as follows: "The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems. A useful, brief definition of a medical error is that it is a preventable adverse event.

Medical errors include errors in diagnosis (diagnostic errors), errors in the administration of drugs and other medications (medication errors), errors in the performance of surgical procedures, in the use of other types of therapy, in the use of equipment, and in the interpretation of laboratory findings. Medical errors are differentiated from malpractice in that the former are regarded as honest mistakes or accidents while the latter is the result of negligence, reprehensible ignorance, or criminal intent.

Medication error

Any incorrect or wrongful administration of a medication, such as a mistake in dosage or route of administration, failure to prescribe or administer the correct drug or formulation for a particular disease or condition, use of outdated drugs, failure to observe the correct time for administration of the drug, or lack of awareness of adverse effects of certain drug combinations. Causes of medication errors may include difficulty in reading handwritten orders, confusion about different drugs with similar names, and lack of information about a patient's drug allergies or sensitivities. When the nurse is in doubt, administration of a drug should be delayed until specifically authorized by a physician. A medication error is "any error occurring in the medication use process." (3)

The National Coordinating Council for Medication Error and Prevention of US (NCC MERP) has approved the following as its working definition of medication error: "... any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems including: prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use." (4)

Not only did the NCC MERP produce the nation's first comprehensive taxonomy for studying medication errors, it also established the following definition of a medication error: A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems (including prescribing; order communication; product labeling, packaging, and no menclature; compounding; dispensing; distribution; administration; education; monitoring; and use) (NCC MERP, 1998-2001). (4)

Medication Error Severity

One of the most important steps in analyzing medication error data is understanding its severity. NCC MERP developed an Index for Categorizing Medication Errors for determining the outcome or effect of the medication error on the patient. (5) The Index contains four major subscales; these include potential for error, actual error that did not reach the patient, actual error that reached the patient but did not result in harm, and actual error that reached the patient and resulted in harm. The Index has a reliability of K = 0.60, determined by a study from researchers at Ohio State University. (6) Kappa (K) is a measure of inter-rater agreement. A value above 0.60 suggests moderate agreement. NCC MERP provides standardized tools and definitions to assist in proper coding of medication errors (NCC MERP, 1998-2001). Based upon accurate classifications, institutions that collect and analyze error data are able to trend patterns of non-harmful and harmful events. (5)

Misdiagnosis

An inaccurate assessment of a patient's condition. Harm may be inflicted on the patient as the result of an incorrect therapeutic approach. The incorrect diagnosis of a morbid condition; a diagnostic error. For example, misdiagnosing a benign tumor as malignant.

Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)

This is an independent, not-for-profit organization, The Joint Commission accredits and certifies more than 17,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards. Their mission is to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. (7)

National Patient Safety Goals

The National Patient Safety Goals (NPSGs) were established in 2002 to help accredited organizations address specific areas of concern in regards to patient safety. The NPSGs underwent an extensive review process in 2009 resulting in revised 2010 NPSGs. (8) ?he Patient Safety Advisory Group works with the Joint Commission staff undertake a systematic review of the literature and available databases to identify potential new NPSGs. This group is comprised of a panel of widely recognized patient safety experts, nurses, physicians, pharmacists, risk managers, and other professionals with hands-on experience in addressing patient safety issues in a wide variety of health care settings. Some of the NPSGs are referred below:

Goal 1--Improve the accuracy of patient identification (use at least two patient identifiers when providing care, treatment and services, eliminate transfusion errors related to patient misidentification).

Goal 2--Improve the effectiveness of communication among caregivers (report critical results of tests and diagnostic procedures on a timely basis).

Goal 3--Improve the safety of using medications (label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings, reduce the likelihood of patient harm associated with the use of anticoagulant therapy).

Goal 7--Reduce the risk of health care-associated infections. Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. Implement evidence-based practices to prevent health care-associated infections due to multidrug-resistant organisms in acute care organizations. Implement evidence-based practices to prevent central line-associated bloodstream infections, implement evidence-based practices for preventing surgical site infections.

Goal 8--Accurately and completely reconcile medications across the continuum of care. A process exists for comparing the patient's current medications with those ordered for the patient while under the care of the organization. When a patient is referred or transferred from one organization to another, the complete and reconciled list of medications is communicated to the next provider of service, and the communication is documented. Alternatively, when a patient leaves the organization's care to go directly to his or her home, the complete and reconciled list of medications is provided to the patient's known primary care provider, the original referring provider, or a known next provider of service. When a patient leaves the organization's care, a complete and reconciled list of the patient's medications is provided directly to the patient and, as needed, the family, and the list is explained to the patient and/or family. In settings where medications are used minimally, or prescribed for a short duration, modified medication reconciliation processes are performed.

Goal 9--Reduce the risk of patient harm resulting from falls.

Goal 14--Prevent health care-associated pressure ulcers (decubitus ulcers). Assess and periodically reassess each resident's risk for developing a pressure ulcer and take action to address any identified risks.

Goal 15--The organization identifies safety risks inherent in its patient population. Identify patients at risk for suicide. Identify risks associated with home oxygen therapy such as home fires.

REFERENCES

(1.) Available at http://www.quic.gov/

(2.) Available at http://www.iom.edu/

(3.) Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L. Relationship between medication errors and adverse drug events. Journal of General Internal Medicine 1995;10(4): 100-205.

(4.) Available at http://www.ismp.org/faq.asp#Question_2

(5.) Available at http://www.medscape.com/viewarticle/586738_3.

(6.) Forrey RA, Pedersen CA, Schneider PJ. Interrater agreement with a standard scheme for classifying medication errors. Am J Health Syst Pharm. 2007;64:175-181.

(7.) Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). Official website available at http://www.jointcommission.org/

(8.) Available at http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/

Irene Christodoulou

Editor in Chief
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Author:Christodoulou, Irene
Publication:Archives: The International Journal of Medicine
Geographic Code:1USA
Date:Jan 1, 2010
Words:1709
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