Medical Errors and Ensuring Patient Safety
December 9, 2003
The Institute of Medicine of the National Academies (IOM) defines a 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." An error may or may not result in an "adverse event," which is an injury caused by medical management rather than by the underlying condition of the patient. IOM surveys show that most people believe that medical errors usually involve drugs, such as a patient getting the wrong prescription or dosage, or mishandled surgeries, such as amputation of the wrong limb. However, there are many other types of medical errors, including diagnostic errors, equipment failure, infections, blood transfusion-related injuries, and misinterpreta-tion of medical orders.
Preventable health care-related injuries cost the economy $17 billion to $29 billion annually; however, the human cost goes beyond price. The IOM asserts that 44,000 to 98,000 people each year die from medical errors. Even the lower estimate is higher than the annual mortality rates from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516).
The unacceptable loss of life or health due to medical error is often accompanied by a loss of faith in the efficacy of health care and health care providers. A survey by the American Society of Health System Pharmacists found that well over half of the people questioned were "very concerned" about being given the wrong medication or experiencing complications from a medical procedure. These concerns can, in turn, lead to the delay or avoidance of medical care, resulting in an immeasurable but real public health problem. More than 97 percent of hospitalizations are completely free of any adverse events, and it is important to recognize that receiving proper health care is far less risky than not doing so.
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. Any effort to reduce medical errors in an organization requires changes to the system design, including possible reorganization of resources by top-level management. Tonight's speakers will show us how improvements in infrastructure, education, and training are being used to maximize patient safety and to make change for the better an immediate and constant priority in today's hospitals and health care facilities.
Distinguished Service Professor of Surgery
Chairman Emeritus, Department of Surgery
Vice Chair for Surgical Research
Professor of Molecular Genetics and Biochemistry
In 1987, after 19 years on the faculty of the University of Minnesota School of Medicine departments of surgery and microbiology, Dr. Simmons joined the University of Pittsburgh School of Medicine as the George Vance Foster Endowed Professor and Chair, Department of Surgery. Dr. Simmons became the medical director of the University of Pittsburgh Medical Center in 1996 and left his position as chair of the Department of Surgery in 1998 to devote more time to his duties as medical director.
Throughout his distinguished career, Dr. Simmons has received many honors, including the Annual Award from the Southwestern Chapter of the American College of Surgeons and the Gift of Life Award from the National Kidney Foundation of Western Pennsylvania. In 1994, he was elected to the Institute of Medicine of the National Academies.
Dr. Simmons has edited or co-authored fifteen books and has written or co-authored over 1200 articles for professional journals, primarily on transplantation, immunology and surgical infections. In the past five years, he has delivered more than a dozen named lectures in this country and abroad. Dr. Simmons is past chair of the Surgical Forum and past president of the Society of University Surgeons, the American Society of Transplant Surgeons, and the Surgical Infection Society.
Associate Professor of Critical Care Medicine
Associate Professor of Internal Medicine
Associate Medical Director, UPMC Presbyterian Hospital
Dr. DeVita joined the University of Pittsburgh School of Medicine faculty as an assistant professor of anesthesiology (now critical care medicine) in 1988 and became an assistant professor of internal medicine in 1989. Dr. DeVita has published over 50 scientific articles, book chapters, and reviews, and has guest-edited numerous publications. He is a member of several professional scientific societies and has delivered educational lectures and led national panel discussions on topics like organ donation and transplantation, palliative care, and medical mistakes and ethics. Among his recent honors are the Mary Jane Kugel Award from the Juvenile Diabetes Research Foundation and a Presidential Citation from the American College of Critical Care Medicine.
Print Resources
Crossing the Quality Chasm: A New Health System for the 21st Century. Institute of Medicine. National Academy Press, 2001.
Demanding Medical Excellence: Doctors and Accountability in the Information Age. Michael L. Millenson. University of Chicago Press, 2000.
Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact. Alexis Herman and Donna Shalala. DIANE Publishing Company, 2000.
Error Reduction in Health Care: A Systems Approach to Improving Patient Safety. Patrice L. Spath. Jossey-Bass, 2000.
Margin of Error: The Ethics of Mistakes in the Practice of Medicine. Susan B. Rubin and Laurie Zubin. University Publishing Group, 2000.
Medical Error: What Do We Know? What Do We Do? Marilynn M. Rosenthal and Kathleen M. Sutcliffe. Jossey-Bass, 2002.
Protect Yourself in the Hospital: Insider Tips for Avoiding Hospital Mistakes for Yourself or Someone You Love. Thomas A. Sharon. McGraw-Hill, 2003.
To Err is Human: Building a Safer Health System. Janet Corrigan, Molla S. Donaldson, Linda T. Kohn, and William C. Richardson. National Academy Press, 2000.
Wall of Silence: The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans. Rosemary Gibson and Janardan Prasad Singh. Lifeline Press, 2003.
Web Resources
www.acponline.org/journals/ecp/
The American College of Physicians-American Society of Internal Medicine
is the nation's largest medical specialty society. Its periodical, Effective
Clinical Practice, available online, publishes many scientific articles
devoted to health care efficiency and eliminating physician error.
www.aha.org
Founded in 1898, The American Hospital Association (AHA) is the national
organization that represents and serves approximately 5,000 hospitals
and health care networks and systems. On its site, the AHA provides
education for health care leaders and information for the public on
health care issues and trends.
www.ihi.org/
The Institute for Healthcare Improvement is a nonprofit organization
that reviews medical errors and health care quality issues. The site
offers in-depth information on improving hospital design and health
care delivery systems and provides links to several patient safety organizations.
www.mdsr.ecri.org/
Medical Device Safety Reports is a repository of independently investigated
medical device incident and hazard information. The site includes a
comprehensive database of approximately 860,000 records compiled since
1977.
www.npsf.org
The mission of the National Patient Safety Foundation is to measurably
improve patient safety in the delivery of health care. The site includes
a bibliography, links to full-length articles, and educational information
on patient safety and how to improve it.
www.patientsafety.gov
The aim of the Department of Veterans Affairs National Center for Patient
Safety is to reduce and prevent adverse medical events in VA hospitals.
The Web site offers medical safety tips for health care consumers, a
list of readings, links to patient advocacy organizations, and downloadable
brochures on ensuring patient safety.
www.talkaboutrx.org
The National Council on Patient Information and Education provides downloadable
information about prescription drug safety, consumer health news, and
links to consumer health organizations and agencies' Web sites.
