Medical errors are responsible for injury in as many as 1 out of every 25 hospital patients; an estimated 48,000-98,000 patients die from medical errors each year. This means that more people die from medical errors than from motor vehicle accidents, breast cancer, or AIDS. Errors in health care have been estimated to cost more than $5 million per year in a large teaching hospital, and preventable health care-related cost the economy from $17 to $29 billion each year. What are Medical Errors?
Medical errors happen when something that was planned as a part of medical care doesn’t work out, or when the wrong plan was used in the first place. Medical errors can occur anywhere in the health care system: • Hospitals. • Clinics. • Outpatient Surgery Centers. • Doctors’ Offices. • Nursing Homes. • Pharmacies. • Patients’ Homes. Errors can involve: • Medicines. • Surgery. • Diagnosis. • Equipment. • Lab reports. They can happen during even the most routine tasks, such as when a hospital patient on a salt-free diet is given a high-salt meal. Most errors result from problems created by today’s complex health care system.
But errors also happen when doctors and their patients have problems communicating. For example, a recent study supported by the Agency for Healthcare Research and Quality (AHRQ) found that doctors often do not do enough to help their patients make informed decisions. Uninvolved and uninformed patients are less likely to accept the doctor’s choice of treatment and less likely to do what they need to do to make the treatment work. Patients at Risk Medical errors may result in: • A patient inadvertently given the wrong medicine. • A clinician misreading the results of a test.
• An elderly woman with ambiguous symptoms (shortness of breath, abdominal pain, and dizziness) whose heart attack is not diagnosed by emergency room staff. Errors like these are responsible for preventable injury in as many as 1 out of every 25 hospital patients. Errors in health care have been estimated to cost more than $5 million per year in a large teaching hospital. According to a recent report by the Institute of Medicine (IOM), preventable health care-related injuries cost the economy from $17 to $29 billion annually, of which half are health care costs.
The IOM report estimates that 44,000 to 98,000 people each year die from medical errors. Even the lower estimate is higher than the annual mortality from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516), thus making medical errors the eighth leading cause of death in the United States. These and other findings of the IOM report are based on research sponsored by a variety of organizations, including the Agency for Healthcare Research and Quality (AHRQ).
For example, a study by AHRQ found that just one type of error—preventable adverse drug events—caused one out of five injuries or deaths per year to patients in the hospitals that were studied How Errors Occur Errors can occur at any point in the health care delivery system, AHRQ-supported research has revealed. Medication Errors These are preventable mistakes in prescribing and delivering medication to patients, such as prescribing two or more drugs whose interaction is known to produce side effects or prescribing a drug to which the patient is known to be allergic.
Research by AHRQ-supported investigators is helping to characterize these errors (called preventable adverse drug events, or ADEs) and suggest how to prevent them. • In a study of inpatient care in two tertiary care hospitals, errors in ordering and administering medicines accounted for 56 and 34 percent, respectively, of preventable adverse drug events. • Findings from a second study showed that dosage errors, in particular, were primarily due to the physician’s lack of knowledge about the drug or about the patient for whom it was prescribed.
• An attempt to identify risk factors for preventable adverse drug reactions among patients admitted to medical and surgical units at two large hospitals found few such factors, which suggested to the researchers that a focus on improving medication systems would prove more effective. Surgical Errors In contrast to ADEs, surgical adverse events (1 in 50 admissions in Colorado and Utah hospitals during 1992), accounted for two-thirds of all adverse events and 1 of 8 hospital deaths in a recent retrospective study of these institutions by an AHRQ fellow.
Diagnostic Inaccuracies Incorrect diagnoses may lead to incorrect and ineffective treatment or unnecessary testing, which is costly and sometimes invasive. Also, inexperience with a technically difficult diagnostic procedure can affect the accuracy of the results. Here, too, AHRQ-funded researchers have made major contributions. • One study showed that physicians who performed 100 or more colposcopies (a test used to follow up abnormal Pap smears) a year had more accurate findings than physicians who performed the procedure less often.
• Another study demonstrated that measuring blood pressure with the most commonly used type of equipment often gives incorrect readings that may lead to mismanagement of hypertension. System Failures Although errors in medication, surgery, and diagnosis are the easiest to detect, medical errors may result more frequently from the organization of health care delivery and the way that resources are provided to the delivery system. Research by AHRQ-supported scientists is helping to identify the systemic factors contributing to preventable adverse events.
• Investigators in a major study discovered that failures at the system level were the real culprits in over three-fourths of adverse drug events. • Failures in disseminating pharmaceutical information, in checking drug doses and patient identities, and in making patient information available are system errors that accounted for adverse drug events in over half of the hospitals studied. • One system-level factor, staffing levels of nurses (adjusted for hospital characteristics), was found in a study to influence the incidence of adverse events following major surgery, such as urinary tract infections, pneumonia, thrombosis, and pulmonary compromise.
This research on systemic problems leads investigators to conclude that any effort to reduce medical errors in an organization requires changes to the system design, including possible reorganization of resources by top-level management. Improving Patient Safety Research funded by AHRQ and others has been important in identifying the extent and causes of errors. Now, additional research is needed to develop and test better ways to prevent errors, often by reducing the reliance on human memory.
Some areas of past research that have shown promise in helping to reduce errors include computerized ADE monitoring, computer-generated reminders for followup testing, and standardized protocols. Computerized ADE Monitoring Although chart review was found in an AHRQ-funded study to be more accurate than computer tracking and voluntary reporting in identifying adverse drug events, it required five times more personnel time. Researchers concluded that the computerized method was the most efficient means of tracking drug errors.
Computer-Generated Reminders for Followup Testing Some diagnostic tests must be repeated to follow up certain conditions, but a small number of such repeat tests are done too early to yield useful results. In contrast, laboratory results showing that a patient needs critical care may not be communicated in a timely manner. • One study funded by AHRQ found that a computerized reminder system to alert physicians to the proper timing of repeat tests reduced the number of patients who were subjected to unnecessary repeat testing.
• The same research group subsequently reported that an automatic alerting system for communicating critical laboratory results reduced the time until appropriate treatment when compared with the existing hospital paging system. Standardized Protocols An AHRQ-sponsored study of patients in intensive care units who had severe respiratory disease found a four-fold increase in survival rate with the use of computerized treatment protocols. Still other investigators are testing computerized decision support systems in various patient populations.
All of these research efforts reflect AHRQ’s commitment to improving patient safety by providing new tools to augment provider judgment. AHRQ-funded research continues to create and test methods to help clinicians avoid errors in health care delivery. An investigation funded by AHRQ and the National Institute on Aging will address the incidence and preventability of adverse drug events in elderly patients receiving ambulatory care. What Can You Do? Be Involved in Your Health Care 1. The single most important way you can help to prevent errors is to be an active member of your health care team.
That means taking part in every decision about your health care. Research shows that patients who are more involved with their care tend to get better results. Some specific tips, based on the latest scientific evidence about what works best 2. Make sure that all of your doctors know about everything you are taking. This includes prescription and over-the-counter medicines, and dietary supplements such as vitamins and herbs. 3. Make sure your doctor knows about any allergies and adverse reactions you have had to medicines. This can help you avoid getting a medicine that can harm you.
4. When your doctor writes you a prescription, make sure you can read it. If you can’t read your doctor’s handwriting, your pharmacist might not be able to either. 5. Ask for information about your medicines in terms you can understand—both when your medicines are prescribed and when you receive them. 6. When you pick up your medicine from the pharmacy, ask: Is this the medicine that my doctor prescribed? 7. If you have any questions about the directions on your medicine labels, ask. Medicine labels can be hard to understand.
For example, ask if “four doses daily” means taking a dose every 6 hours around the clock or just during regular waking hours. 8. Ask your pharmacist for the best device to measure your liquid medicine. Also, ask questions if you’re not sure how to use it. 9. Ask for written information about the side effects your medicine could cause. 10. If you have a choice, choose a hospital at which many patients have the procedure or surgery you need. Research shows that patients tend to have better results when they are treated in hospitals that have a great deal of experience with their condition.
11. If you are in a hospital, consider asking all health care workers who have direct contact with you whether they have washed their hands. 12. When you are being discharged from the hospital, ask your doctor to explain the treatment plan you will use at home. This includes learning about your medicines and finding out when you can get back to your regular activities. Research shows that at discharge time, doctors think their patients understand more than they really do about what they should or should not do when they return home. 13.
If you are having surgery, make sure that you, your doctor, and your surgeon all agree and are clear on exactly what will be done. 14. Speak up if you have questions or concerns. 15. Make sure that someone, such as your personal doctor, is in charge of your care. This is especially important if you have many health problems or are in a hospital. 16. Make sure that all health professionals involved in your care have important health information about you. 17. Ask a family member or friend to be there with you and to be your advocate (someone who can help get things done and speak up for you if you can’t).
18. Know that “more” is not always better. It is a good idea to find out why a test or treatment is needed and how it can help you. You could be better off without it. 19. If you have a test, don’t assume that no news is good news. Ask about the results. 20. Learn about your condition and treatments by asking your doctor and nurse and by using other reliable sources. References AHRQ medical errors research AHRQ Publication No. 00-PO58 Replaces AHCPR Publication No. 98-PO18 Current as of April 2000.