Impact of medical errors on the physician
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The field of patient safety considers how to ensure that patients do not suffer ill effects due to their medical treatment; it also covers how to handle such consequences if and when they arise.
From the outset, three concepts should be distinguished:
Adverse outcome: an unsatisfactory outcome that arises as part of the natural course of the disease (e.g., a gastrointestinal bleed in a pneumonia patient due to a duodenal ulcer);
Adverse event: “unintended injuries or complications that are caused by health care management, rather than by the patient’s underlying disease, and that lead to death, disability at the time of discharge or prolonged hospital stays” (G.R. Baker et al. "The Canadian Adverse Events Study" CMAJ 2004; 170: 1678-86).
Adverse events include complications that arise from treatment, inherent (and often unforeseeable) risks of interventions, and errors. An example of a complication from treatment would be a gastrointestinal bleed in a pneumonia patient who is taking warfarin for his atrial fibrillation. Even if the dose of warfarin was within the appropriate range, it could still have contributed to the bleed, but this was not an error.
Medical error: a category of adverse event that conveys an implication of blame. An example would be if the pneumonia patient is prescribed clarithromycin for the pneumonia, without the dose of warfarin being adjusted. This is because clarithromycin is known to potentiate the warfarin effect, which would become excessive. Because many adverse events come from inherent risks and not from errors, it is prudent to use the term "adverse event" unless error has definitively been established. Errors must be prevented, but this requires a culture of open communication and quality improvement that may be discouraged by a culture of blame.
The 2004 Canadian Adverse Events study (Baker et al. CMAJ 2004; 170:1678) placed the incidence of adverse events in Canadian hospitals at 7.5 per hundred acute care hospital admissions, or 185,000 per year, of which close to 70,000 (37%) were preventable. An estimated 9,250 to 23,750 deaths per year could have been avoided.
A Glossary of terms related to patient safety from the Agency for Healthcare Research and Quality’s Patient Safety Network
The CBC Radio Podcast “White Coat Black Art” After the Error series looks at the impact of medical error on a family.
Several agencies deal with patient safety and adverse events. They study safety and propose guidelines for staff and education for patients:
•Agency for Healthcare Research and Quality
•Veterans Health Administration National Center for Patient Safety
• American National Patient Safety Foundation
• International System Safety Society. The system safety concept applies systems engineering and systems management to analysing hazards.
The issue of patient safety was brought to public attention in 1999 by the Institute of Medicine’s document “To Err is Human: Building a Safer Health System”. The report noted:
“The human cost of medical errors is high. Based on the findings of one major study, medical errors kill some 44,000 people in U.S. hospitals each year. Another study puts the number much higher, at 98,000. Even using the lower estimate, more people die from medical mistakes each year than from highway accidents, breast cancer, or AIDS.”
The report further suggests that:
“The majority of medical errors do not result from individual recklessness but from basic flaws in the way the health system is organized. Stocking patient-care units in hospitals, for example, with certain full-strength drugs – even though they are toxic unless diluted – has resulted in deadly mistakes. And illegible writing in medical records has resulted in administration of a drug for which the patient has a known allergy. Medical knowledge and technology grow so rapidly that it is difficult for practitioners to keep up. And the health care system itself is evolving so quickly that it often lacks coordination. For example, when a patient is treated by several practitioners, they often do not have complete information about the medicines prescribed or the patient's illnesses.”
Much earlier, however, Ivan Illich, in "Medical Nemesis" (Lancet 1974; i:918-921) had written:
"Within the last decade, medical professional practice has become a major threat to health. Depression, infection, disability, dysfunction, and other specific iatrogenic diseases now cause more suffering than all accidents from traffic or industry. Beyond this, medical practice sponsors sickness by the reinforcement of a morbid society which not only industrially preserves its defectives but breeds the therapist's client in a cybernetic way. Finally, the so-called health-professions have an indirect sickening power – a structurally health-denying effect... which I designate medical Nemesis. By transforming pain, illness, and death from a personal challenge into a technical problem, medical practice expropriates the potential of people to deal with their human condition in an autonomous way and becomes the source of a new kind of un-health."
Patient Safety depends upon the establishment of a safety culture. This means committing to safety within all levels of a health organization from frontline healthcare workers to management and the board of directors of a facility.
Achieving a safety culture requires a number of critical elements such as:
1. Preventing adverse events before they occur:
2. During the event:
3. After the event:
Note the parallel between this three-part approach and the Haddon Matrix for injury prevention.
Cognitive biases may lead a clinician to make diagnostic mistakes. A useful list is given by Crosskerry (Ref: Croskerry P. The importance of cognitive errors in diagnosis. Acad Med 2003; 78: 775-80. http://www.jround.co.uk/error/reading/crosskerry1.pdf ).
The WHO has identified "Five Elements of the Global Patient Safety Challenge". These include blood safety; immunization safety; safe clinical procedures; safe water, and hand hygiene. They have an extensive web site listing articles, guidelines and resources (link).
Writing Orders or Charting: Terms You Should Avoid
Here are some terms that can be easily misread or confused, leading to adverse events. This list was developed by the Joint Commission on Accreditation of Healthcare Organizations:
Here are other symbols and terms you should avoid:
- "µg" can easily be mistaken for mg (milligrams), resulting in a thousand-fold overdose. Use "mcg" instead;
- "D/C" – does this mean discharge or discontinue?
- Write drug names in full: abbreviations often cause confusion;
- Avoid "P.d." or "OD" meaning per diem or once daily - confused with oculus dexter (right eye);
- Avoid " per os" meaning orally. Use "by mouth" or "orally";
- "qn" (meaning nightly, at bed time) can be misread as "qh" meaning every hour;
- "q.o.d." meaning every other day can be misinterpreted as q.d. (daily) or as q.i.d. (4 times each day);
- "sub q" meaning subcutaneous; the q can be misinterpreted as "every". Use "subcutaneous";
- "IU" meaning international units can be misread as "IV" (intravenous). Use "units";
- Beware of running names and doses together: "Inderal40mg" can be misread as "Inderal 140 mg".
Handwriting has been known to be an issue with physicians (link to some cartoons). Maybe you have not yet learned to write badly, but here are some warnings as your calligraphy deteriorates:
- @ can be mistaken for the number 2;
- > (greater than) can be mistaken for number 7;
- < (less than) can be mistaken for the letter L;
- cc can be mistaken for U (units) when written unclearly. Use "mL".
If an adverse event occurs you are faced with the very challenging task of disclosing it to the patient and their family. Medical errors are commonly not disclosed to patients, but this is changing (Levinson et al. CMAJ 2007;177:265). In 2010, the CPSO updated its policy on disclosure of harm, aiming to de-stigmatize medical errors.
The Canadian Medical Protective Association advises you to disclose an adverse event to the patient and family as soon as feasible. Do not wait until the patient asks questions. The CMPA suggests the following approach to communication (September 2006 information sheet):
There is an excellent CMPA web page on Communicating with your patient about harm. Patients whose physicians continue to support them through an adverse outcome are less likely to litigate. Patients may litigate for many reasons:
Once a legal proceeding has begun, your communication with the patient should be exclusively via the CMPA legal counsel (1-800-763-1300).
Before the meeting(s)
During the meeting(s)
After the meeting(s)
(G. Wallace. The ins and outs of disclosure. Royal College Outlook 2006;3(2):55)
Expressions of regret (“I regret that this happened to you” or “I was sorry to learn of the pain that you and your family have experienced”) is not an acceptance of blame. But avoid the phrase “I am sorry about this ” as it can be misunderstood as “I am sorry that I did this to you”. Good communication at this point can often direct attention away from a litigious approach. Some U.S. states, and British Columbia, have specific legal protection for apologies so that the doctor’s apology cannot later be used in court against him or her. In other provinces, apologies can be used in court proceedings against the physician.
Here are some useful CMPA resources: (by courtesy of Dr. Gordon Wallace)
- An article "How to apologize to patients." French version of the same article
- Disclosing adverse events to patients." French version
- CMPA Glossary of terms relating to patient safety
- Guide to obtaining informed consent
When an adverse event occurs, there is nearly always a second victim – the members of the medical team involved in the event. The impact on the physician or team members may go unnoticed as institutional support and concern from colleagues is often lacking.
This is partly due to a well-established culture of blame. It is often much easier to identify a scapegoat than to identify and change the weaknesses in the system that may have led to the error.
Dr. Albert Wu discussed this in an article titled "Medical Error: the second victim". He notes that
"Virtually every practitioner knows the sickening realization of making a bad mistake. You feel singled out and exposed–seized by the instinct to see if anyone has noticed. You agonise about what to do, whether to tell anyone, what to say. Later, the event replays itself over and over in your mind. You question your competence but fear being discovered. You know you should confess, but dread the prospect of potential punishment and of the patient's anger. You may become overly attentive to the patient or family, lamenting the failure to do so earlier and, if you haven't told them, wondering if they know. Sadly, the kind of unconditional sympathy and support that are really needed are rarely forthcoming. While there is a norm of not criticizing, reassurance from colleagues is often grudging or qualified."
(A. Wu "Medical Error: the second victim the doctor who makes the mistake needs help too" BMJ 2000;320:726–7)
This article highlights aspects of our current culture that are being addressed in order for a culture of safety to grow and become more ingrained in our medical system. A supportive environment for the affected medical staff promotes disclosure of events and near-misses, allowing for system changes to be made to prevent future episodes from occurring. Furthermore, it allows the affected individuals to heal and recover from such an event
Legal supports for physicians are available through the Canadian Medical Protective Association. In addition, the Physician Health Program provides support for physicians experiencing stress and work-related conflict.
Proposals have been made that malpractice claims should be removed from the normal legal tort system and brought before a special "Health Court" system. Here is an article (Milbank Memorial Fund Quarterly, 2006; 84(3) on "Health Courts and Accountability for Patient Safety").
Updated January 10, 2018