TEDMED Great Challenges: Eliminating Medical Errors
All humans make mistakes. Doctors and nurses are human; they make mistakes. All systems are imperfect. Medical professionals use systems.
- Errors by medical professionals and systems are inevitable. Unfortunately, they send 2.4 million patients to hospitals yearly and are directly linked to 200,000 annual fatalities.
Regardless of methods used to detect, prove and compensate for medical errors, how much better can we do in reducing or eliminating medical errors and what areas should we focus on to get the best improvements?Members of the Great Challenge Team, Eliminating Medical Errors, gathered on a Google+ Hangout to discuss the topic in a virtual round-table event on January 10, 2013. Watch the video below.
- Every year an estimated 2.4 million medical errors occur that are associated with about 200,000 deaths, according to the United States Centers for Disease Control and Prevention. The health care professionals on this panel were most interested in who has the information or knows the best practices to reduce these numbers.“We tend to lump errors into a box, saying there is such a thing as infection or tumors or fracture. That is lovely, but we are never going to be able to address them unless we are able to understand them at a more granular level,” said Michael Victoroff of COPIC, Inc. “We need to begin to parch them out in terms of which are preventable, which are unavoidable, which are minor, major, which are intercepted, which have terrible consequences.” Victoroff suggested that health care professionals need to learn to separate the seriousness of the error from the seriousness of the effect.
- “Tremendous strides have been made but still need improvements,” said Paula Griswold of the MA Coalition for the Prevention of Medical Errors. “We are still introducing more complexity in the way care is delivered that creates new potential for error, more medications, more tools that are used and more organizations trying to work together.”
Research is being done to decrease errors, but the consensus is that there is still a long way to go.Many contributed their thoughts to the #greatchallenges Twitter conversation:
- The dialogue about this issue extended well past the Google+ hangout. Over the past year, the conversation around Eliminating Medical Errors as one of TEDMED's 20 Great Challenges foc used on several key questions.
What are the top 10 contributing factors for the Great Challenge "Eliminating Medical Errors"?Many weighed in on the dialogue.
Our Challenge Team members discussed eliminating medical errors throughout the past year:
Response from Helen Haskell:
I will begin with definitions. In its 1999 report, To Err is Human, the Institute of Medicine, following James Reason, defined medical error as "the failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim." But the Institute for Healthcare Improvement prefers to focus on the concept of medical harm, or "unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment, or hospitalization, or that results in death."
This has been the focus of recent studies in this area. There are those who think that our failure to reduce patient harm results from the emphasis on error rather than harm. Focus on proven error is a failure of imagination in an area where it is probably not wise to draw the boundaries too narrowly: as has been amply demonstrated by dramatic reductions in central line infections and birth complications, until we try to prevent adverse events we do not necessarily know which ones are preventable.
I therefore focus here on what I see as the contributing factors to medical harm, not just medical error. And since this question is both ambiguous and important, I will answer it in two ways: first with an unsystematic list of some of the most common types of harm that I have heard reported by patients over 12 years of talking to medical error victims; and second with a list of the top factors cited by both patients and providers, over and over, as contributing to that harm.
- Unnecessary treatment or tests, which can lead to a cascade of unneeded medical treatment, ultimately resulting in harm.
Top types of harm:- Healthcare-associated infection leading to sepsis or other serious consequences. Healthcare-associated infections include surgical site infections, urinary tract infections, central line infections, and intestinal infections like clostridium difficile, among others.- Failure to rescue a deteriorating patient from a medical or surgical complication. The result, by definition, is death.- Diagnostic error: Why is this so common and what can we do about it? Delay in treatment due to early misdiagnosis or bureaucratic delay in getting a needed appointment.- Error in prescribing, such as wrong medication, wrong dose, or failure to recognize circumstances indicating that a drug is inappropriate for a particular patient.- Other adverse drug events: Adverse medication events are common in hospital inpatients and also a significant cause of hospital admissions.- Surgical mishaps, such as lacerations, perforations or surgical fires.- Falls, a common cause of harm in hospitals and residential facilities.- Pressure ulcers, which develop when immobilized patients are not moved enough to take weight off high-pressure areas like the heels or coccyx.
Beyond TEDMED's Great Challenges, the issue of eliminating medical errors received large amounts of attention in the past year - with many tackling how best to reduce these preventable, expensive and often tragic errors.
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