Medical Errors

This page covers the two-part lecture series on medical errors. =Objectives, lecture 1=

=Objectives, lecture 2=

Define Institute of Medicine patient safety terms.
Below are succinct definitions of IOM nomenclature:
 * patient safety
 * freedom from accidental injury


 * accident
 * An event that damages a system and disrupts the ongonig or future output of a system


 * medical error
 * the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.


 * active error
 * an error tha toccurs at the level of the front line operatore whose effects are felt almost immediately


 * latent error
 * and error in design, organization, training, or maintenance that leads to operator errors and whose effects typically lie dormant in the system from length periods of time prior to their appearance


 * adverse event
 * an injury caused by medical management rather than by the underlying disease or condition of the patient
 * adverse events are further classificed as preventable, nonpreventable, associated with medication side effects or administration, and negligence.

Describe the interplay between medical systems and individuals that can lead to medical errors.

 * Error producing conditions include high cognitive loads and decision density, frequent interruptions, transitions of care, fatigure, insufficient supplies, excessive communication load, high noise levels, overcrowding (eg. ER), and time pressures.
 * The medical culture socializes physicians to strive for practice that is error free and does not appropriately emphasize error reporting. "This culture sets the stage for an unrealistic trainingn standard and internal conflict when a resident makes a mistake."
 * The education relationship between residents and attending physicians has potential pitfalls. An active partnership is necessary to prevent redundant orders, unclear responsibilities, etc.
 * Errors of execution are sometimes followed by errors of communication. Physicians are reluctant to disclose errors due to guilt, fear of professional stigma, and litigation from patients.

Distinguish a bad outcome from a medical error.

 * An example of a bad outcome is a patient with a kidney transplant who develops lymphoma from chronic immunosuppression; this is a bad outcome but it is a consequence of medical error.
 * An example of a medical error is the lack of sterile procedure when inserting a central venous line leading to bacteremia.

Describe who should, when and how to disclose a medical error to a patient.

 * ASAP, even if all details are not known
 * With honesty and compassion
 * The physician who established the therapeutic relationship should make the disclosure. In team care, the attending or most senior team member should make the disclosure.
 * Answer any patient questions
 * Explain how lessons will be learned.

Describe how to responding to patient emotions in the event of adverse outcomes with and without medical error
=Links & References=
 * With honesty and compassion
 * Apologizing does not increase lawsuits.