Current Situation of Medical Errors Prepared by Asma Alshammari Alhanoof Alaniz Teflah Ali Mai Alrweeli Munyfaa Aldhafeeri Norah Almoteri Introduction Health care processes are increasingly being implicated in causing harm to patients

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Current Situation of Medical Errors Prepared by Asma Alshammari Alhanoof Alaniz Teflah Ali Mai Alrweeli Munyfaa Aldhafeeri Norah Almoteri

Introduction

Health care processes are increasingly being implicated in causing harm to patients. Medical errors and adverse events are primarily responsible for this harm. These errors, which may occur at every level of the custom are both common and diverse in nature. Medical errors can occur anywhere in the health care system in hospitals, clinics, surgery centers, doctors' offices, nursing homes, pharmacies, and patients' homes and can have serious consequences. Errors can involve medicines, surgery, diagnosis, equipment, or lab reports. Medical errors represent a serious public health problem and pose a threat to patient safety. As health care institutions establish “error” as a clinical and research priority, the answer to perhaps the most fundamental question remains elusive: What is a medical error? To reduce medical error, accurate measurements of its incidence, based on clear and consistent definitions, are essential prerequisites for effective action.

Despite a growing body of literature and research on error in medicine, few studies have defined or measured “medical error” directly. Instead, researchers have adopted surrogate measures of error that largely depend on adverse patient outcomes or injury (i.e., are outcome-dependent).

A lack of standardized nomenclature and the use of multiple and overlapping definitions of medical error have hindered data synthesis, analysis, collaborative work and evaluation of the impact of changes in health care delivery. Medical error is defined as “failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim”. A medical error is a threat to patient safety and has a negative effect on health as well.

 

 

 

Definition of Medical Error

 

Medical error the term “error” has been variously defined. The Oxford Dictionary of Current English (1998) defines it as “mistake” or the condition of being morally “wrong”. Error has also been defined in a wider context as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim (Reason, 1990). Although the definition of “error” has its origins in behavioral psychology, the term is appropriate for medical usage. Using Reason's definition, IOM has tried to separate medical error into two parts (Kohn et al., 2000): the first half of the definition constitutes “error of execution” and the latter half, “error of planning.” In this context, two other related terms, “adverse event” and “patient safety.” Bates et al. (1997) defined adverse events as injuries that result from medical management, rather than from the underlying disease. Patient safety, as defined by IOM, is freedom from accidental injury (Kohn et al., 2000). All three terms, “medical error,” “adverse event,” and “patient safety” complement one another.

 

 

 

 

 

 

 

 

 

 

 

Type of medical error

· Their two types of medical error according to moral and medical error according to sit or event

 

Medical error According to moral:

 

 

Error is a disorder of an intentional act, and they distinguish between errors in planning an act and errors in its execution. If a prior intention to reach a specified goal leads to action, and the action leads to the goal, all is well. If the plan of action contains some flaw, that is a ‘mistake’. If a plan is a good one but is badly executed, that is a failure of skill.

This approach Mistakes can be divided into

· knowledge-based errors:

Knowledge-based errors can be related to any type of knowledge, general, specific, or expert. It is general knowledge that penicillin's can cause allergic reactions; knowing that your patient is allergic to penicillin is specific knowledge; knowing that co-fluampicil contains penicillin's is expert knowledge. Ignorance of any of these facts could lead to a knowledge-based error.

 

· rule-based errors. Failures of skill can be divided into

Rule-based errors can further be categorized as

the misapplication of a good rule or the failure to apply a good rule;

the application of a bad rule.

· action-based errors ('slips', including technical errors)

An action-based error is defined as ‘the performance of an action that was not what was intended. A slip of the pen, when a doctor intends to write diltiazem but writes diazepam, is an example. Technical errors form a subset of action-based errors. They have been defined as occurring when ‘an outcome fails to occur or the wrong outcome is produced because the execution of an action was imperfect’ An example is the addition to an infusion bottle of the wrong amount of drug

· memory-based errors (‘lapses’).

Memory-based errors occur when something is forgotten; for example, giving penicillin, knowing the patient to be allergic, but forgetting.

 

How to prevent this type of error:

Knowledge-based errors can obviously be prevented by improving knowledge,

e.g., by ensuring that students are taught the basic principles of therapeutics and tested on their practical application and that prescribers are kept up to date. Computerized decision-support systems can also train prescribers to make fewer errors

Mistakes that result from applying bad rules, or misapplying or failing to apply good rules (rule-based errors), can be prevented by improving rules.

Training can help in preventing technical (action-based) errors.

Memory-based errors are the most difficult to prevent. They are best tackled by putting in place systems that detect such errors and allow remedial actions. Check lists and computerized systems can help.

 

 

The second typey of medical error: According to sit or events 

 

1/ medication

Type of medication error

· .Prescribing error

· Omission error

· .Wrong time error

· Unauthorized drug

· Improper drug error

· Wrong dose form error

· Wrong dose preparation error

· Wrong administration technique errors

· .Deteriorated drug errors

· Monitoring error

· Compliance error

How to prevention of medication error

· Failure mode and effects analysis

· Legal requirements

· Policies & procedures

· Education and training

· Standardized order forms

 

2/ surgical

Types of surgical error

· Failure to diagnose a dangerous medical condition during surgery

· Operating on the wrong part of a patient’s body

· Damaging healthy organs during surgery

· Leaving instruments in a patient’s body following surgery

· Failure to prevent or fix complications during surgery

 

How to prevent surgical error

· Mark the operation sits

· Improving communication in operation room

· Use new technology in operation room

3/ diagnostic error

· Diagnostic

· Error or delay in diagnosis

· Failure to employ indicated tests

· Use of outcome ded tests or investigations

· Failure to act on results of monitoring or testing

· Preventive

· Failure to provide prophylactic treatment

· Inadequate monitoring or follow -up of treatment

· Treatment

· Error in the performance of an operation , procedure , or therapy

· Error in administering the treatment

· Error in the dose or method of using a drug

· Avoidable delay in treatment or in responding to an abnormal test

· Inappropriate ( not indicated ) care

·

4/ infection error

Types of infection error like Viruses, bacteria, parasites, fungus, and prions are different types of pathogens that cause infections.

How to prevent infection:

· Wash your hands often, especially before and after preparing food, going to the bathroom, and after other dirty tasks.

1. Have a specially trained and dedicated infection control staff

1. Regularly educate all surgeons and staff on infection control measures

1. Vaccinate and treat personnel for exposure to infection at all times

1. Implement computer-assisted decision support and reminders that help doctors know when and how much antibiotic or other medication to give

 

nosocomial infection

1. Staphylococcus aureus

1. Escherichia coli

1. Candida

1. Methicillin

 

Causes by

3. Urinary catheters (urinary tract infections)

3. Surgical procedures (surgical site infections)

3. Central vinos catheters (blood sternum infection)

3. Mechanical ventilation (pneumonia)

 

How to prevent nosocomial infections

0. Frequent hand hygiene is the most important preventative measure to limit the spread of pathogens.

0. Compliance with isolation precautions

0. Proper use of personal protective equipment

0. Avoidance of unnecessary use of indwelling devices, and remove them as soon as advisable.

0. Practicing proper aseptic and/or sterile techniques during insertion and maintenance of devices.

4. Routine disinfection of surfaces, patient equipment, and medical devices

4. Appropriate waste management

 

5/ blood transfusion

blood transfusion mistakes occur when

1. incorrect blood is given to a patient. For instance, a blood sample may be mislabeled.

1. incorrect patient name may be marked on a blood sample,

1. blood sample is marked with the incorrect blood type (O-negative, etc.).

1. too much blood given to patient

1. blood is stored at incorrect temperatures

 

How prevent blood transfusion error

1. training of medical staff, including nurses and technicians.

1. Mack sour that the correct blood group to correct

 

 

RULES AND PROGRAMS FOLLOWED IN THE HOSPITAL TO REDUCE MEDICAL ERRORS IN SAUDI ARABIA

 

The Minister of Health, Dr. Abdullah bin Abdulaziz Al-Rabiah is following with great interest the work of the technical committees that were recently established within each health facility to detect the medical error as soon as it occurs without the need for a complaint and linking the procedures for practicing the health service according to a mechanism that is followed up electronically, which is known as the “electronic dashboard” system. Dashboard in hospitals, which enhances the level of health service and contributes to reducing medical errors.

The Ministry of Health has set procedures to reduce medical errors, including:

1- Requiring all health personnel to register professionally with the Saudi Commission for Health Specialties.

2- Continuing medical education for all health personnel, as a condition for re-registration.

3- Requiring all health personnel to train in clinical skills

4- Implementing a program to monitor and measure severe events.

5- Implementing a performance measurement program.

6- Implementation of the clinical review program.

7- Adopting treatment protocols and establishing the rules of evidence-based medicine.

8- Creation of quality committees in the ministry and directorates of health affairs. 9- Implementing the performance indicators measurement program.

10- Creating committees to examine and approve the qualifications and experience of doctors.

11- Supporting infection control programs in hospitals and developing the skills of workers.

12- Strengthening health awareness programs inside and outside hospitals.

13- Developing an evaluation program for clinical and non-clinical departments in hospitals by experts in the same field.

14- Improving nursing skills and requesting nursing competencies from developed countries.

15- Introducing a bridging program for all technicians.

16- Introducing patient satisfaction measurement programs.

17- Medical file repair program.

18- Establishment of medical performance review committees.

 

Many medical errors are not reported by healthcare professionals due to fear of retribution and may be concealed by patients and their families in the sense that reporting them may be pointless. As long as there is no system in place to report and address medical errors, these conditions will not improve.

The Saudi Center for Accreditation of Health Facilities is now developing a system according to which it will receive and study the current cases of serious accidents that occur in approved facilities, serious medical errors and serious accidents to be reported.

The Ministry of Health has identified the following events that need to be reported: 1- Diagnostic or therapeutic procedure for the wrong patient 2- Performing surgery in the wrong place 3- Serious damage caused by blood transfusion 4- Suicide in the hypnosis department 5- Forgetting surgical tools and pads 6- Wrong medication that leads to death or serious complications 7- Handing over a newborn to non-parents 8- Baby kidnapping 9- Maternal mortality 10- An unexpected death 11- Unexpected loss of a party or function of a member 12- Air embolism of a blood vessel

Starting in January 2016, hospitals accredited by the Saudi Center for Accreditation of Health Institutions must report all serious accidents by filling in and submitting the Serious Accident Reporting Form on the electronic portal of the Saudi Center for Accreditation of Health Facilities. This is within (5) working days from the internal notification of the serious accident (the date on which the hospital administration was notified of the accident). This must be followed by a Root Cause Analysis (RCA) and a risk reduction action plan within (30) business days from the date of notification of the serious accident. A root cause analysis is a formal process of investigations aimed at identifying the root causes of adverse adverse events. The Saudi Center for Accreditation of Health Facilities encouraged all health facilities as well as the beneficiaries From its services, patients and reviewers are required to report serious medical errors to which they were a party, and support everything that would achieve this. The policy followed by the Saudi Center related to reporting serious medical errors states that we are a mandatory report to all approved health facilities and a voluntary initiative for non-accredited health facilities. And those that connect to the council by other means (informed means - the patient - a relative)

The most prominent benefits of reporting serious medical errors: 1. Know the medical errors that occur in hospitals  The various medical centers and how their causes were, and what are the results of the radical analysis of them and the corrective plan that was implemented, the Saudi Center for Accreditation of Health Facilities and all other health facilities greatly helps in learning the lessons learned from those mistakes in order to help avoid them in the future. 2. Reporting Medical Errors A practical guide provided by health facilities to the public who benefit from their services as an indication of their Its commitment to the required transparency in recognizing deficiencies when they occur. 3. Reporting medical errors helps health facilities through the advisory services provided by the Saudi Center for Accreditation of Health Institutions related to the fundamental analysis of the error and the development of the corrective plan.  4. Reporting Medical Errors The Saudi Center for Accreditation of Health Facilities assists in carrying out practical research aimed at determining the rates and types of medical errors and methods of combating them, and disseminating the results of those studies to all sectors of the health community in the Kingdom. 5. Reporting medical errors is evidence of the approved health facilities' commitment to the policy of maintenance and follow-up accreditation by the Saudi Center for Accreditation of Health Facilities.

 

 

 

 

 

 

 

 

 

 

 

 

 

COMMON CAUSES OF MEDICAL ERRORS :

Factors associated with health care professionals:

· Lack of therapeutic training

· Inadequate drug knowledge and experience

· Inadequate knowledge of the patient

· Inadequate perception of risk

· Overworked or fatigued health care professionals

· Physical and emotional health issues

· Poor communication between health care professional and with patients  are the most common causes of medical errors. Whether verbal or written, these issues can arise in a medical practice or a healthcare system and can occur between a physician, nurse, healthcare team member, or patient. Poor communication often results in medical errors

Factors associated with patients

· Patient characteristics (e.g., personality, insufficient patient education and language barriers)

· inappropriate patient identification

· failure to obtain consent

· insufficient patient education.

· Complexity of clinical case, including multiple health conditions, polypharmacy and high-risk medications.

Factors associated with the work environment

· Workload and time pressures

· Distractions and interruptions (by both primary care staff and patients)

· Lack of standardized protocols and procedures

· Insufficient resources n Issues with the physical work environment (e.g., lighting, temperature and ventilation)

· Inadequate staffing alone does not lead to medical errors but can put healthcare workers in situations where they are more likely to make a mistake.

 

Factors associated with medicines

· Naming of medicines

· Labelling and packaging

Factors associated with tasks

· Repetitive systems for ordering, processing and authorization

· Patient monitoring (dependent on practice, patient, other health care settings, prescriber)

Factors associated with computerized information systems

· Difficult processes for generating first prescriptions (e.g. drug pick lists, default dose regimens and missed alerts)

· Difficult processes for generating correct repeat prescriptions

· Lack of accuracy of patient records

· Inadequate design that allows for human

· Technical failures can include complications or failures with medical devices, implants, grafts, or pieces of equipment.

 

 

Advice Help To Prevent Medical Errors

 

Medical errors can occur anywhere in the health care system: hospitals, clinics, surgery centers, doctors' offices, nursing homes, pharmacies, and patients' homes. Errors can involve medicines, surgery, diagnosis, equipment, or lab reports. These tips tell what you can do to get safer care.

How to Reduce or Prevent Medical Errors in health care system :

Following steps are important in reducing or preventing medical errors:

· Make a center for patient safety within the agency for health care research and quality:

· Make national goals for patient safety

· Follow the progress in the meeting for the recognized goals

· Form mandatory reporting systems regarding collection and interpretation of medical mistakes

· Make the standards and expectations for improvement in safety high via the actions and support of oversight organizations

· Make safety systems inside the healthcare organizations via the use of safe practices at the delivery level

· Make an accurate patient’s identification

· Increase the effectiveness of communication among the patients and the providers

· Timely reporting of important tests

· Label all the medications

· Transfer accurately the medication information to nurses

· Fulfill the hand hygiene guidelines and thus decrease the risk of infection

· Make a universal agenda for preventing wrong site, wrong patient and wrong procedure and follow it .

· Complete the pre-procedure verification

· Ensure the safe place for medication preparation

· Reduce interruptions during drug administration

· Use calculator to calculate the exact dose

· Separate and label of drugs with similar names, colors or sounds

· Check whether medication is given to proper patient

· Nursing education regarding calculation of dose

· Delivery of drugs from pharmacy to ward under supervision of staff nurse

· Double checking of medications via two separate nurses

· Follow the rule of right i.e. right patient, right drug, right dose, right route and right time

· Head nurse must report the medication error when it occurs

· Nurses must have access to patient’s information

· Increase the patient-nurse ratio in each shift

· Attendance of educational programs

· Make and follow medication administration policy

 

Advice Help To Prevent Medical Errors For patient :

The best 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.

1. Make sure that all of your doctors know about every medicine you are taking.

2. Bring all of your medicines and supplements to your doctor visits.

3. Make sure your doctor knows about any allergies and adverse reactions you have had to medicines. When your doctor writes a prescription for you, make sure you can read it.

4. Ask for information about your medicines in terms you can understand—both when your medicines are prescribed and when you get them:

o What is the medicine for?

o How am I supposed to take it and for how long?

o What side effects are likely? What do I do if they occur?

o Is this medicine safe to take with other medicines or dietary supplements I am taking?

o What food, drink, or activities should I avoid while taking this medicine?

5. When you pick up your medicine from the pharmacy, ask: Is this the medicine that my doctor prescribed?

6. If you have any questions about the directions on your medicine labels, ask.

7. Ask your pharmacist for the best device to measure your liquid medicine.

8. Ask for written information about the side effects your medicine could cause.

1. If you are in a hospital, consider asking all health care workers who will touch you whether they have washed their hands.

1. When you are being discharged from the hospital, ask your doctor to explain the treatment plan you will follow at home.

1. If you are having surgery, make sure that you, your doctor, and your surgeon all agree on exactly what will be done. Having surgery at the wrong site (for example, operating on the left knee instead of the right) is rare. But even once is too often. The good news is that wrong-site surgery is 100 percent preventable. Surgeons are expected to sign their initials directly on the site to be operated on before the surgery.

1. If you have a choice, choose a hospital where many patients have had 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.

1. Speak up if you have questions or concerns. You have a right to question anyone who is involved with your care.

1. Make sure that someone, such as your primary care doctor, coordinates your care. This is especially important if you have many health problems or are in the hospital.

1. Make sure that all your doctors have your important health information. Do not assume that everyone has all the information they need.

1. Ask a family member or friend to go to appointments with you. Even if you do not need help now, you might need it later.

1. 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.

1. If you have a test, do not assume that no news is good news. Ask how and when you will get the results.

20- Learn about your condition and treatments by asking your doctor and nurse and by using other reliable sources.

 

 

 

 

 

 

Conclusion Medical errors are one of the most important quality problems in health care today. All providers know medical errors create a serious public health problem that poses a substantial threat to patient safety. Part of the solution is to maintain a culture that works toward recognizing safety challenges and implementing viable solutions rather than harboring a culture of blame, shame, and punishment. Healthcare organizations need to establish a culture of safety that focuses on system improvement by viewing medical errors as challenges that must be overcome. All individuals on the healthcare team must play a role in making the provision of healthcare safer for patients and healthcare workers. Often it is difficult to recognize one’s mistake, but it is necessary to face the situation and try to learn from it so that future errors can be prevented. Identifying the risk factors for medical errors is crucial first step towards its prevention and is important goal of quality care assurance.